P1. Electrolytes< Na+, K+, Ca++

P2. IV therapy< Indications, types, needles, etc

P3. Types of IV solutions< Hypertonic, hypotonic, isotonic (indications for

each)

P4. Math calculations

P5. Crystaloid versus Colloid

P6. Complications of IV’s

P IV fluids and medications, and totalparenteral nutrition will be considered.

P IV therapy and safe administration of IVmeds is very critical because absorption inpharmacokinetics is eliminated.

PWhat the nurse puts into the vein isimmediately distributed, there is no takingback a mistake.

P It is critical for the nurse to be very familiarwith all drugs and electrolyte solutionsadministered IV.

Intravenous FluidsOverview

Net movement of fluids withincompartments

PFluid loss:< GI: diarrhoea, vomiting, etc.< renal: diuresis< vascular: haemorrhage< skin: burns

PFluid gain:< Iatrogenic:< Heart / liver / kidney failure:

Fluid shifts in disease

Renal regulation of sodium andpotassium balance

PMost abundant cation (90% of the electrolytefluid) and the chief base of the blood.

PPrimary functions are to chemically maintainosmotic pressure, acid base balance and totransmit nerve impulses.

PNormal level is 135 -145 mEq/L

Sodium (Na+) Discussion

Background

PCauses include: Severe burns, CHF , Edema(dilutional) , NG suction

PExcessive fluid loss (severe diarrhea,vomiting, sweating), drugs such as diuretics

PExcessive IV induction of non electrolytefluids (glucose), diabetic acidosis

PAddison’s disease, malabsorption syndrome

PSevere nephritis, pyloric obstruction,Hypothyroidism

Sodium (Na+) 000000000Hyponatremia (a decreased level) reflects a relative excess

of body water, rather than a low total sodium level.

PCauses include: Dehydration d/t insufficientwater intake, Primary aldosteronism

PComa, Cushing’s disease, Diabetes insipidus

PTracheobronchitis

Sodium (Na+)00000000000000

Hypernatremia (an increased sodium level) is uncommon

PMost abundant principle electrolyte of theintracellular fluid (90 % found within the cell)

PPrinciple function relates to electrical activityof heart, acid base balance, nerveconduction

PNormal value is 3.5 -5.3 mEq/L

Potassium (K+)

Background

PCauses include: diarrhea, vomiting,starvation, malabsorption

PExcessive sweating, Draining wounds, burns,

PRespiratory alkalosis, Diuretics, DKA

Potassium (K+)

Hypokalemia (decreased levels) is the shifting of K+ intocells, K+ loss from GI and biliary tracts, renal K+ excretion,

and reduced K+ intake:

Potassium (K+)

Slide

POnly ionized calcium can be used by thebody in such vital processes as:

PMuscular contraction, cardiac function,transmission of nerve impulses, and bloodclotting

PNormal values: 8.6 -10.0 mg/dl

Calcium (CA++)

Background

PCauses: alkalosis, pancreatitis,hyperphosphatemia, immobility, removal ofparathyroids during surgery

Calcium (Ca++)

Hypocalcemia (decreased total calcium)

Calcium (Ca++)

Trousseau’s sign

Calcium (Ca++)

Chvostek’s sign

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

PPeripheral IV therapy is the most commonmethod of gaining access to the client’svenous system.

PUsed to replace fluids, electrolytes, andnutrient losses, anti-infectives, bloodproducts, Dyes

POrders are necessary for initiation of therapy= (1) Specific type of solution; (2) Rate ofadministration; (3)Volume of infusion; (4)Time of infusion intended

Intravenous therapy

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

P1.Establish or maintain a fluid or electrolyte balance

P2 Administer continuous or intermittent medication

P3 Administer bolus medication

P4 Administer fluid to keep vein open (KVO)

P5 Administer blood or blood components

P6 Administer intravenous anesthetics

P7 Maintain or correct a patient's nutritional state

P8 Administer diagnostic reagents

P9 Monitor hemodynamic functions

Indications for an IV

PSteel Needles: Eg: Butterfly catheter. Theyare named after the wing-like plastic tabs atthe base of the needle.

PThey are used to deliver small quantities ofmedicines, to deliver fluids via the scalpveins in infants, and sometimes to drawblood samples (although not routinely, sincethe small diameter may damage blood cells).These are small gauge needles (i.e. 23gauge).

P

TYPES OF NEEDLES

POver the Needle Catheters Example:peripheral IV catheter. This is the kind ofcatheter you will primarily be using.

PCatheters (and needles) are sized by theirdiameter, which is called the gauge.

PThe smaller the diameter, the larger thegauge.

PTherefore, a 22-gauge catheter is smallerthan a 14-gauge catheter.

PObviously, the greater the diameter, themore fluid can be delivered. To deliver largeamounts of fluid, you should select a largevein and use a 14 or 16-gauge catheter. Toadminister medications, an 18 or 20-gaugecatheter in a smaller vein will do.

PFor example, a patient comes into the EDwith gastroenteritis and is dehydrated fromvomiting and diarrhea.

PAcutely, she receives a fluid bolus to expandher intravascular volume. Her bloodchemistry shows that her electrolytes are abit off, so the IV fluid is adjusted to bringthem within normal parameters.

PShe is also given medication for nausea viaher IV. She will remain on maintenance IVfluids until she is able to drink adequateamounts of fluids.

P Isotonic fluids

PHypertonic fluids

PHypotonic fluids

Types of IV FLUIDS

PClose to the same osmolarity as serum. Theystay inside the intravascular compartment,thus expanding it.

PCan be helpful in hypotensive or hypovolemicpatients.

PCan be harmful. There is a risk of fluidoverloading, especially in patients with CHFand hypertension.

PExamples: Lactated Ringer's (LR), NS(normal saline, or 0.9% saline in water).

Types of IV FLUIDSIsotonic fluids

P Isotonic fluids contain an approximatelyequal number of molecules (blue dots) asserum so the fluid stays within theintravascular space.

P Remember that fluid flows from an area oflower concentration of molecules to an areaof high concentration of molecules (osmosis)to achieve equilibrium (fluid balance).

P In this example, there is no fluid flow into orout of the intravascular space.

PHave less osmolarity than serum (i.e., it hasless sodium ion concentration than serum). Itdilutes the serum, which decreases serumosmolarity. Water is then pulled from thevascular compartment into the interstitial fluidcompartment. Then, as the interstitial fluid isdiluted, its osmolarity decreases which drawswater into the adjacent cells.

P Can be helpful when cells are dehydratedsuch as a dialysis patient on diuretic therapy.May also be used for hyperglycemicconditions like diabetic ketoacidosis, in whichhigh serum glucose levels draw fluid out ofthe cells and into the vascular and interstitialcompartments.

PCan be dangerous to use because of thesudden fluid shift from the intravascularspace to the cells. This can causecardiovascular collapse and increasedintracranial pressure (ICP) in some patients.

PExample: .45% NaCl, 2.5% dextrose

Hypotonic fluids

PHypotonic fluids contain a lower number ofmolecules than serum so the fluid shifts fromthe intravascular space to the interstitialspace (represented by the green arrows).

P This decreases the interstitial spaceosmolarity (because of the increase of fluidand constant number of molecules within it)which then causes fluid to move into thecells. Note that the green arrows representfluid movement, not molecule movement.

PHave a higher osmolarity than serum. Pullsfluid and electrolytes from the intracellularand interstitial compartments into theintravascular compartment. Can helpstabilize blood pressure, increase urineoutput, and reduce edema.

PRarely used in the prehospital setting. Caremust be taken with their use. Dangerous inthe setting of cell dehydration.

PExamples: D5W.45% NaCl, D5WLR, D5WNS, blood products, and albumin

Hypertonic fluids

PHypertonic fluids contain a higher number ofmolecules than serum so the fluid shifts fromthe interstitial space to the intravascularspace (represented by the green arrows).

P This increases the interstitial spaceosmolarity (because of the loss of fluid andconstant number of molecules within it) whichthen causes fluid to leak out of the cells.

PCrystalloid

PColloid

There are two main groups offluids

PAre isotonic and remain isotonic and aretherefore, effective volume expanders for ashort period of time.

PHowever, both the water and the electrolytesin the solution can freely cross thesemipermeable membranes of the vesselwalls (but not the cell membranes) into theinterstitial space, and will achieve equilibriumin two to three hours.

PThey are ideal for patients who need fluidreplacement.

PWhen using an isotonic crystalloid for fluidreplacement to support blood pressure fromblood loss< remember that 3 mL of isotonic crystalloid

solution are needed to replace 1 mL of patientblood. This is because approximately two thirds ofthe infused crystalloid solution will leave thevascular spaces by about one hour.

Crystalloid

PGenerally, a good rule of thumb is that initialcrystalloid replacement should not exceedthree liters before whole blood is instituted.

P Continued use of crystalloids runs the veryreal risk that the fluid that has leaked into theinterstitial space will result in edema,primarily in the lungs (pulmonary edema).

PExamples: Lactated Ringer's (LR), NS(normal saline).

Crystalloid

PThese contain molecules (usually proteins)that are too large to pass out of the capillarymembranes and therefore remain in thevascular compartment.

PThe large protein molecules give colloidsolutions a very high osmolarity. As a result,they draw fluid from the interstitial andintracellular compartments into the vascularcompartment.

PThey work well in reducing edema (as inpulmonary or cerebral edema) whileexpanding the vascular compartment.

PColloids can produce dramatic fluid shifts andplace the patient in considerable danger ifthey are not administered in a controlledsettings.

PExamples: albumin and steroids

Colloid

PReplace blood with blood

PReplace plasma with colloid

PResuscitate with colloid

PReplace ECF depletion with saline

PRehydrate with dextrose

The rules of fluid replacement:

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

PWhat are the expected losses ?

PWhat are the expected gains ?

How much fluid to give ?

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

P

P Insensible:< sweat< exhaled

What are the expected losses ?

POral intake:< fluids< nutritional supplements< bowel preparations

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

What are the potential gains ?

P1. Digital Dorsal veins

P2. Dorsal Metacarpal veins

P3. Dorsal venous network

P4. Cephalic vein

P5. Basilic vein

Veins of the Hand

P1. Cephalic vein

P2. Median Cubital vein

P3. Accessory Cephalic vein

P4. Basilic vein

P5. Cephalic vein

P6. Median antebrachial vein

Veins of the Forearm

PMicrodrip sets Allow 60 drops (gtts) / mLthrough a small needle into the drip chamber

P Macrodrip sets Allow 10 to 15 drops / mLinto the drip chamber

Flow Rates

PFluid may be ordered at a KVO or TKO rate.This means to Keep the Vein Open, or run influids very slowly, enough to keep the veinopen, but not really deliver much volume.

PAt times, you may desire a faster flow rate.This is usually expressed in mLs / hour. Inother words, how much fluid do you wantyour patient to receive each hour? Acommon "maintenance" amount, forinstance, would be "run it in at 125 an hour".Your patient would receive 125 mL of fluidevery hour.

PUnless you are using an electronic pump todeliver the fluid at precise amounts, you willneed to learn how to set a flow rate yourself.This is usually done by counting the numberof drops that fall into the clear drip chamberon the IV administration set in one minute.To do this, you must know what sizeadministration set you are using (micro ormacrodrip). Plug the numbers into thefollowing formula and you've got it!

P (volume in mL) x (drip set) gtts

P ------------------------------------ = ------

P (time in minutes) min

Intravenous Fluids

PWho Needs Them?

PWhat’s Maintenance?

PHow Much H20?< 100 cc/kg/d 1st 10 Kg< 50 cc/kg/d 2nd 10 Kg< 20 cc/kg/d for every Kg > 20 Kg

PNa?

PK?

PDextrose?

P

Maintenance IV Fluids

P70 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

Maintenance IV Fluids

POrder reads 1000ml of 5 percent dextrose inwater (D5W) at 125 ml/ h. You haveavailable 20 drop factor tubing. Calculate thedrops per minute.< ML/hrX DF 125X20

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

– Minutes

Calculation

POrder reads 3000ml of a multiple electroytefluid over 24 hours. You have available 20drop factor tubing. Calculate the drop perminute.

PFormula:

P ml/h X DF 125 X 20– ---------------- = --------------- = 42 gtt/min– Minutes 60

P

POrder to read: Order: Nipride 1 g IV in 250mL D5w at 4 mcg/kg/min for a patientweighing 250. Administer at _____ mL/hr?

Phttp://home.sc.rr.com/nurdosagecal/

Phttp://www.accd.edu/sac/nursing/math/default.html

Complicated IV calculations

PBruising - may occur at any time during anepisode of intravenous therapy

Complications Of IVs

Bruising

P Infection - adhering to aseptic technique isvital in the prevention of intravenous relatedinfections. Asepsis should be maintained atinsertion, during clinical use and at removalof the device.

Cellulitis

P Infiltration - the inadvertent administration ofnon-vesicant solution/medication intosurrounding tissues.

PAlthough the solution is non-vesicant, tissuedamage may still occur.

PRegular monitoring of infusion sites, choiceof correct access device/intravenousdressing and the use of in-line pressuremonitors may help to reduce the extent towhich infiltration occurs

PDiscontinue the IV, place cold compress onto decrease swelling then warm compress tomove fluid out of the interstitial spaces

Infiltrate

PExtravasation - the inadvertent administrationof a vesicant substance into the tissues canhave disastrous outcome.

Extravasation

P Infusion Phlebitis - inflammation of the veinassociated with infusion phlebitis is seen inthis photograph. Careful/regular monitoringof intravenous access sites is recommended.

Phlebitis

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

Systemic Complications

PParental nutrition is the administrationthrough a central or other intravenous line ofessential proteins, amino acids,carbohydrates, vitamins, minerals, traceelements, lipids, and fluid.

PUsed to improve or stabilize the nutritionalstatus of cachectic or debilitated patients whocannot take or absorb oral nutrition tomaintain their nutritional status.

PAdverse effects many include mechanicalproblems (IV lines), infections, metabolicimbalances, gallstone development, nausea

Parental nutrition (TPN)(Hyperalimentation)

PTPN solutions are hyperosmotic (three to sixtimes the osmolarity of normal blood)

PFluid shifts can stimulate fluid shifts betweenbody fluid compartments.

PHyperglycemia (hyponatremia andhypokalemia) can cause osmotic diruresis =dehydration

P If client has an accompanying cardiac orrenal dysfunction = over hydration, CHF,pulmonary edema

TPN