Intravenous Fluids

Management of clients with Fluid and Electrolyte Disturbances

Advantage Preferred route for administering fluids, electrolytes and drugs in emergency

Disadvantage Drug and solution incompatibility Adverse reactions Infections complicstion

Management of clients with Fluid and Electrolyte Disturbances

Crystalloids Solutions with small molecules that flow easily from the bloodstream into the cells and tissues
Isotonic Hypotonic hypertonic

Colloids Act as plasma expanders Always hypertonic; pulls fluid from cells into the bloodstream Requires close monitoring for signs and symptoms of hypervolemia
Albumin Plasma protein fraction Dextran

Management of clients with Fluid and Electrolyte Disturbances

Types of IVF according to tonicity

Isotonic solutions Hypotonic solutions Hypertonic Solutions

Management of clients with Fluid and Electrolyte Disturbances

Isotonic solutions
Osmolality: 250-300 mOsm/kg Have a concentration of dissolved particles or tonicity equal to the intracellular fluid. Osmotic pressure is therefore the same inside and outside the cells, so they neither shrink nor swell with fluid movement. Eg. D5W, PNSS, PLR

Management of clients with Fluid and Electrolyte Disturbances

Intravenous Fluids: Isotonic

Solution
D5W

Uses
Fluid loss dehydration

Special Considerations
- Solution is isotonic initially; becomes hypotonic when dextrose is metabolized - Dont use for resuscitation - Use cautiously in renal or cardiac disease - doesnt provide enough daily calories for prolonged use

PNSS

Shock, Hyponatremia, Resuscitation, BT, DKA, Hypercalcemia, Metabolic Alkalosis

- dont use in patients with heart failure, edema, hypernatremia

LR

Dehydration, burn, Lower GIT fluid - No magnesium loss, acute blood loss, - Dont use in patients with renal failure or hypovolemia d/t 3rd space shifting, with liver disease mild metabolic acidosis, salicylate overdose
Management of clients with Fluid and Electrolyte Disturbances

Hypotonic Solutions
Osmolality: < 250 mOsm/kg Have tonicity less than the ICF, so osmotic pressure draws water into the cells from the ECF It makes the cell swell Contraindicated: Increase ICP, Liver Dse, burn, trauma Ex. Half-normal saline, 0.33% NaCL, D2.5W
Management of clients with Fluid and Electrolyte Disturbances

Intravenous Fluids: Hypotonic

Solution Uses Special Considerations

.45% NaCL (halfnormal saline solution)

Water replacement DKA after initial NSS and before dextrose solution Hypertonic dehydration Na and CL depletion Gastric fluid loss from vomiting of NGT lavage

-Use cautiously; can cause Cardiovascular collapse or increase ICP -Dont use in patients with liver disease, trauma or burns

Management of clients with Fluid and Electrolyte Disturbances

Hypertonic Solution
Osmolality: >300mOsm/kg Tonicity is greater than that of ICF, so osmotic pressure is unequal inside and outside the cell It draws fluid from the intracellular space causing the cells to shrink and extracellular space to expand. Contraindication/Caution: DKA, cardiac or renal disease
Management of clients with Fluid and Electrolyte Disturbances

Intravenous Fluids: Hypertonic

Solution Uses Special Considerations D5NSS Hypotonic dehydration - Dont use in patients with Temporary treatment of cardiac or renal disease circulatory insufficiency and shock if plasma expanders arent available
D10W Water replacement Conditions in which some nutrition with glucose is required Monitor serum glucose

Management of clients with Fluid and Electrolyte Disturbances

Delivery methods
Potential IV site: metacarpal, cephalic, basilic, median cubital, greater saphenous veins Choose the right site Needle size matters:
the higher the size, the smaller the diameter of the needle

Management of clients with Fluid and Electrolyte Disturbances

Complications of IV therapy
Infiltration Infection Phlebitis Thrombophlebitis extravasation

Management of clients with Fluid and Electrolyte Disturbances

Infiltration
Fluid leaks from the vein into surrounding tissue Occurs when the access device dislodges from the vein
coolness at the site pain swelling leaking lack of blood return

Management: Stop the infusion remove IV catheter elevate the extremity apply warm compress
Management of clients with Fluid and Electrolyte Disturbances

Go Small to prevent infiltration

Use the smallest catheter Avoid placement in joint areas Anchor the catheter in place

Management of clients with Fluid and Electrolyte Disturbances

Infection
The primary barrier to infection is punctured
Purulent drainage at the site tenderness Erythema Warmth or hardness on palpation Systemic: fever, chills, inc. WBC

Management of clients with Fluid and Electrolyte Disturbances

Monitoring vital signs is vital

Check vital signs and notify the physician Swab the site for culture Remove the catheter as ordered Maintain aseptic technique

Management of clients with Fluid and Electrolyte Disturbances

Phlebitis and thrombophlebitis

Phlebitis is the inflammation of veins Thrombophlebitis is an irritation of the vein with the formation of a clot and usually more painful than phlebitis
pain redness Swelling or induration at the site Red line streaking along the vein Fever Sluggish flow of the solution
Management of clients with Fluid and Electrolyte Disturbances

Prevention begins with big veins

Remove the IV Monitor vital signs Notify the physician Apply warm soaks at the site Choose large veins and change the catheter every 72 hours to prevent this complication

Management of clients with Fluid and Electrolyte Disturbances

Extravasation
Similar to infiltration This results when medications (dopamine, calcium solutions, and chemo drugs) seep through veins and produce blistering and eventually necrosis.
Initially: discomfort and burning sensation at the site Skin tightness blanching Lack of blood return
Management of clients with Fluid and Electrolyte Disturbances

Review the policy

Stop the infusions Notify the doctor Apply ice early and warm soaks later Elevate the extremities Assess the circulation and nerve function of the limb When giving drugs that may extravasate, know the hospitals policy
Management of clients with Fluid and Electrolyte Disturbances

Severed catheter
Occurs when a piece of catheter becomes dislodged and is set free in the vein
Pain at the fragment site Decreased BP cyanosis Loss of consciousness Weak and rapid pulse

Management
Apply tourniquet above the site of pain Notify the physician immediately Monitor the patient Avoid reinserting a needle through its plastic catheter once the needle has been withdrawn
Management of clients with Fluid and Electrolyte Disturbances

Allergic reaction
Red streak extending up the arm Rash itching Watery eyes and nose wheezing

Management
Stopping the IVF immediately Notify the physician immediately Monitor the patient Giving oxygen and medication as ordered

Management of clients with Fluid and Electrolyte Disturbances

Air embolism
Occurs when air enters the vein
decrease in blood pressure increase in PR respiratory distress increase ICP Loss of consciousness

Management
Notify the physician and clamp the IV Place the patient on his left side and lower his head Monitor VS and administer oxygen To avoid serious complication, prime all tubing completely, and tighten all connections securely
Management of clients with Fluid and Electrolyte Disturbances

Speed shock
Occurs when IV solutions or medications are given too rapidly
Facial flushing Irregular pulse Severe headache Decrease blood pressure Loss of consciousness and cardiac arrest

Management
clamp the IV and Notify the physician immediately Monitor VS and administer oxygen administer medication as ordered Infusion control device can prevent this complication
Management of clients with Fluid and Electrolyte Disturbances

Fluid overload
Happens gradually or suddenly, depending on how well the patients circulatory system can accommodate the fluid.
Neck vein distention Puffy eyelids Edema Weigh gain Increased BP Increased RR SOB, cough and crackles

Management
Slow the IV rate, notify the physician and monitor VS Keep the patient warm, keep the head of bed elevated Give oxygen and other medication (diuretic) as order
Management of clients with Fluid and Electrolyte Disturbances

Blood Products and Blood Transfusion

Management of clients with Fluid and Electrolyte Disturbances

Blood Transfusion
Restores blood volume, correct deficiencies in the bloods oxygen carrying capacity and its coagulation components, or replace WBC in patients who need them Nurses need to be knowledgeable about the various blood products available to safely transfuse blood to their patients
Management of clients with Fluid and Electrolyte Disturbances

Compatibility
Blood contains various antigens that affect how compatible one persons blood is with anothers. The antigen include: ABO blood group, Rh factor and Human Leukocyte Antigen(HLA) blood group

Management of clients with Fluid and Electrolyte Disturbances

ABOs of typing blood

Identifies two antigens on RBC--- A and B
A person has both A and B antigens (type AB) only one antigen (type A or type B) or neither (type O)
A antigen has anti-B antibodies floating freely in the plasma B antigen has anti A antibodies floating freely in the plasma

Type AB universal recipients Type O universal donors Ideally transfusion should be done using the same type of blood as the patient
Management of clients with Fluid and Electrolyte Disturbances

Blood-type compatibility
Recipients blood type A B AB O Compatible donor type A, O B, O A, B, AB, O O

Management of clients with Fluid and Electrolyte Disturbances

Rhesus (Rh) factor

About 85% of US population in Rh-positive, which means possessing Rh antigen, an antigen found on the membrane of RBC Rh negative people may develop Rh antibody if exposed to Rh positive blood
1st exposure: sensitization 2nd exposure: fatal hemolytic reaction (can occur
during transfusion or pregnancy)

Management of clients with Fluid and Electrolyte Disturbances

Management of clients with Fluid and Electrolyte Disturbances

Fixing an Rh problem
If an Rh negative patient is exposed to Rhpositive blood, an injection of Rh0(D) immune globulin can be given within 72 hours of exposure. Rh0(D) immune globulin inhibits antibody formation Common preparation include: RhoGAM

Management of clients with Fluid and Electrolyte Disturbances

Human Leukocyte Antigen (HLA)

Located on the surface of circulating platelets, WBC and most tissue cells Responsible for febrile reactions in patients receiving a transfusion that contains platelets from several donors In that instance antigen-antibody reaction causes platelet destruction As a result, patient becomes less responsive to platelet transfusion
Management of clients with Fluid and Electrolyte Disturbances

Types of Blood products

Fresh Whole blood
Used unless the patient has loss more than 25% of total blood volume. Used to treat hemorrhage, trauma, or major burns Should be avoided if fluid overload is present ABO compatibility and Rh matching
Management of clients with Fluid and Electrolyte Disturbances

Types of Blood products

Packed RBC
Prepared by removing about 90% of the plasma surrounding the cells and adding an anticoagulant preservative Helps in restoring or maintaining the oxygen carrying capacity of the blood in patients with anemic conditions or can correct blood losses during or after surgery ABO compatibility and Rh matching
Management of clients with Fluid and Electrolyte Disturbances

Types of Blood products

WBC
Rarely indicated; however they may be used to treat gram-negative sepsis or progressive soft tissue infection thats unresponsive to microbial. HLA compatibility and Rh matching

Management of clients with Fluid and Electrolyte Disturbances

Types of Blood products

Fresh Frozen Plasma (FFP)
Prepared by separating the plasma from the RBCs and freezing it within 6 hours of collection Used to treat hemorrhage, expand plasma volume, correct undetermined coagulation factor deficiencies, replace specific clotting factors and correct factor deficiencies resulting from liver disease Rh matching
Management of clients with Fluid and Electrolyte Disturbances

Types of Blood products

Cryoprecipitate (factor VIII)
Insoluble portion of plasma recovered from FFP Used to treat hypofibrigenemia, factor VIII deficiency (antihemophilic factor), hemophilia A, DIC

Management of clients with Fluid and Electrolyte Disturbances

Types of Blood products

Albumin
Extracted in plasma and contains globulin and other proteins Used for patients who have acute liver failure, burns, trauma or who have had surgery as well as for neonates with hemolytic disease when crystalloids prove ineffective

Management of clients with Fluid and Electrolyte Disturbances

Types of Blood products

Platelet
Used for patients who have platelet dysfunction or thrombocytopenia Rh matching

Management of clients with Fluid and Electrolyte Disturbances

Blood transfusion procedure

Before starting BT: Informed consent, explain the procedure Cultural consideration VS (notify physician if febrile) If receiving other medication, it should not be mix with blood products Doctors order regarding BT to prevent errors Triple check the patients identity (right transfusion at the right time) If with previous transfusion
Management of clients with Fluid and Electrolyte Disturbances

How to avoid BT errors

Match the patients name, medical record numberm ABO, Rh status, blood bank identification numbers with the label on the blood bag Check expiration date Have the other nurse verify the information Sign the blood slip, filling the required data. The blood slip will prove useful if the patient develops an adverse effect Double-check the doctors order Be sure that the blood was typed and cross-matched within the last 48hours
Management of clients with Fluid and Electrolyte Disturbances

Blood transfusion procedure

During BT: Maintain sterile technique Observe standard institutional policies and standard precautions Flush with NSS before and after infusing blood products Infuse blood products through at least an 18G or 20G IV catheter Transfuse blood using a Y-type IV administration set with filter and infuse the blood over 2 to 4 hours When starting the transfusion, remain with the patient and observe carefully for first 15 minutes Use a pressure bag or specialized infusion pump to administer blood more rapidly, if needed
Management of clients with Fluid and Electrolyte Disturbances

 When giving platelet concentrate, it should be transfused over 15 minutes Check platelet count 1 hour after the transfusion ends

Management of clients with Fluid and Electrolyte Disturbances

Blood transfusion procedure

After BT: Monitor patients status Watch for signs of fluid overload, especially in elderly patients Obtain laboratory test Document: Patients identification Identification of blood products, including date of expiration VS before, during and after BT Date, time, type, amount and duration of transfusion Adverse reaction and actions taken Patient response, including laboratory results Assessment after transfusion Patient teaching
Management of clients with Fluid and Electrolyte Disturbances

Blood transfusion reaction

Management of clients with Fluid and Electrolyte Disturbances