clinical meas of fluid/electrolyte balance Flashcards
3 clinic measurements nurse can initiate regarding fluid balance
weights,
fluid intake/output,
vital signs
each kg of fluid lost is equal to how many litres
what is an acute change in weight
1
• Significant changes (more than 2kg in a week or more or 1kg in a day indicate acute fluid changes)
• These fluid changes indicate changes in body fluid volume not a specific compartment
how do vitals change in response to fluid imbalances or lyte imbalance
- Tachycardia is early sign of hypovolemia
- Pulse volume inc in FVE and dec in FVD
- Irreg pulse w electrolyte imbalance
- Changes in resp rate and depth may be compensatory mechanism or may cause resp acid-base imbalances
- BP (sensitive meas or blood volume changes) may fall significantly with FVD and hypovolemis or inc w FVE and overhydration
- Postural or ortho HoTN may also occur with hypovolemia
how do you assess orthostatic hypotension
• To assess orth HoTn: put cuff on pt. Meas it while theyre upine. Let rest 3-5 minutes and again after theyve stood measure. A drop in 10-15mmHG in systolic and with corresponding drop in diastolic pressure and an inc pule rate b 10+ bpm it indicates ortho or postural hypotension
how to record intake
what is put on the balance
• To measure fluid intake, each item of fluid consumed or admin is recorded specifying the time and type
o Oral fluids: etc and soup, include water taken w meds
o Ice chips. Record as pprox half of what was consumed 200ml=100ml fluid
o Foods that become liquid at room temp eg gelatine, jello, ice cream. Don’t measure foods that are pureed as theyre solid foods in a diff form
o Tube feedings-include volume of water instilled before and after med admin, intermittent or continouous feedings, residual checks
o Parenteral fluids-the exact amount of IV fluid admin is to be recorded, since some fluid containers may be overfilled include blood transfusions
o Iv meds continuous or intermittent
o Catheter or tube irrigants-fluids used to irrigate NG tubes if not immediatel withdrawn
fluid output. what is recorded
Fluid output
o Urinary output-following ea voiding meas. In ICU its meas hourly. If incontinent say how many times, can meas soaked area on sheets. Can weigh diapers for infants. Each gram of weight left from the weight of the soiled is equivalent to 1ml if urine is freq soiled can record the # of voidings
o Vomitus and liquid feces: amount, type, time
o Tube drainage: amount, type, time
o Wound and fistula drainage: document type and # of dressings or linens saturated w drainage or specific volume if using hemovac
when do you total i and o
how do you know if they match up
at end of shift
o To det if changes are proportional or changes in fluid status compare A. Total i/o in 24hrs and B. Both with previous measurements
o Inc in serum osmolarity indicates what
fluid volume deficit
what does an inc in urine specific gravity indicate
how would it be in FVE vs FVD
o When conc of solutes in urine is high (FVD) the specific gravity rises when conc is low FVE the specific gravity is low
romoting healthy fluid and elextrolyte balance (instructions for pts)
romoting healthy fluid and elextrolyte balance (instructions for pts)
o Consume 2-2.5l water daily
o Avoid hgh salt, sugar, caffeiene
o Eat balanced diet
o Limit alcohol intake as its diuretic
o Inc fluid intake before, during and after strenuous exercise.
o Replace lost electrolytes
o Maintain normal BMI
o Learn about and monitor side e of meds
o Seek prompt care for notable signs of fluid imbalance: sudden weight gain or loss, dec urine volume, swollen ankles, SOB, dizziness or confusion
which solns are isotonic
Isotonic solutions:
0.9% sodium chloride (NS),
Lactated Ringers or
Ringer’s solution
5% dextrose in water
what occurs w isotonic solns
what do you assess for them
what are they used for
Initially remain in vascular compartment expanding vascular volume.
Assess for hypervolemia (bounding pulse and SOB)
Used to replace fluid and electrolytes for pts w continuing losses eg gastric suction or wound drainage or more commonly to restore vascular volume particularly after trauma or surgery
which isotonic soln is electrolyte balanced
Ringer’s is physiologic (electrolyte) balanced.
which isotonic soln must you be wary of liver fx and why. what is this soln given for
lactated ringer’s contains NaCL, K, \Ca (which are all i Ringer’s) plus lactate which when metb in the liver forms HCO3. It is therefore an alkalinizing soln used to treat metabolic acidosis
D5W iso, hypo, hypertonic once in the plasma? what is it used for and contraindicated for?
Becomes hypotonic in plasma as dextrose is rapily metb leaving only free water and expanding intracellular and extracellular fluid volumes. Don’t use for pts at risk of inc intracranial pressure can->cerebral edema. is pt diabetic
eg of hypotonic soln
- 45% NaCl half normal saline,
- 33% NaCl one third normal saline
although it is hypertonic D5 1/2NACl becomes hypotonic once in the plasma as the dextrose is rapidly metb
considerations for hypotonic solns
Hypototnic solutions are used to give free water and treat cellular dehydration. Promote waste elim by kidneys. Don’t give to clients as above IICP as it can cause cerebral edema, or third space fluid shift
if too much is given the cells will pull water into them and rupture
egs hypertonic solns
5% dextrose in normal saline (D5NS).
5% dextrose in 0.45% NaCl (D5 1/2NS. This becomes hypotonic in plasma as dextrose is metb),
5% dextrose in lactated ringer’s (D5LR)
cosiderations for admin of hypertonic solns
Hypertonic draw fluid out of intracellular and interstitial compartments into the vascular compartment, expanding vascular volume
Don’t give to pts w kidney or heart diease or pts who are dehydratd
Watch for signs of hypervolemia.
diabetic?
nutrient solutions good for and not good for
examples
o contain some form of carbs for energy and nutrients. Useful in preventing dehydration and ketosis but don’t give enough calories for wound healing, weight gain, or normal growth in kids
o Eg D5W and D5 ½ NS
some examples of acidifying solns
o Acidifying solutions are 5% dextrose in 0.45% sodium chloride and 0.9% sodium chloride solution
volume expanders
eg
fx
Volume expanders
o Solutions used to inc the blood volume followig blood loss or loss of plasma
o Eg albumin and human serum albumin
when is butterfly IV most often used
for short term use (
how long are IV catheters
o A peripheral short catheter is less than or equal to 7.6cm in length
how should catheters be stabilized
no longer w tape. now w manufactured catheter stabilization device
when would a glass bottle be used with an IV
considerations for this
when the med in it is incompatible w plastic
These require an air vent so it can replace the fluid
o Some bottle contain a tube that serves as a vent. They usually have filter
what would cause you to return the iv soln bag and not use it
o Cloudiness, evi that the containers been tampered w or opened before or leaks=don’t use and return to pharmacy
if past expiration date
_________is kept sterile and inserted into the solution container when the equipment is set up and ready to start
insertion spike
if you dont need continuous infusion but you may want to have venous access in the future what do
o Intermittent infusion lock may be created by attaching a sterile injection cap or device to an existing IV catheter. This keeps venous access avail for admin of intermittent or emergency medications. Commonly referred to as saline lock
(this is the IVI which we flush w NS to keep blood from coagulating)
Iv filters fx
problems that can arise
Intravenous filters
o Used to remove air and particulate matter from IV infusion and to reduce the risk f complications
o Some problems assoc w filters include A) clogging of the filter surface, which may stop or slow the flow rate when debris accumulates B) binding of some drugs eg insulin and amphotericin B to the surface of the filter
before prepping an IV infusiont he nurse shoud
Before prepping an IV infusion the nurse must det the following
o The type and amount of solution to be infused
o The exact amount (dose) of any med to be added to a compatible solution
o The rate of flow or the time over which the infusion is to be completed
is the soln the correct one? expiry? cloudy? etc…diabetic? liver fx? etc
• check approved online database. Drug ref book or pharmacist about IV fluids composition, purpose, potential incompatabilities and side effects
o Understanding the purpose of the infusion is as imp as assessing the client
o Should question an order for 5% dextrose in water at 150ml/h if the pt has peripheral edema and other signs of fluid overload
flow rates above what should be assessed every 15-30min
150ml/hr
in order to monitor an IV infusion what pertinent data do you need
o Gather pertinent data: type and sequence of solutions to be infused, determine the rate of flow and infusion schedule
you go to ensure that the correct solution is being infused and its not the right one. what do
o (if incorrect slow the rate of flow to a minimum to maintain the patency of the catheter. Unless if the pt is at risk for dev adverse rxn then stop it and the catheter shoukd be saline-locked. Stopping the infusion completely allows a thrombus to form in the IV catheter. When this happens the catheter must be removed and new venipunctur.
o Change solution to correct one. Document and report the error, according to agency protocol
if an IV rate is too slow or too fast can you change it
if it were infusing too fast what would you assess
o If rates too fast check policy may cause significant inc in blood volume
o Assess for symptoms of hyervolemia=bounding pulse, dyspnea, rapid laboured breathing, cough, crackles in lung bases, tachycardia
o If too slow may be able to adjust but check policy. May need drs order
how could you manipulate the catheter and bag to det if it is still in lumen
o Det catheter pos by lowering the solution below the level of the infusion site and observe for a return flow of blood from the vein absence of blood may indicate its no longer in vein or that the tip is partially obstructed by a thrombus, vein wall or a valve in the vein (with some catheters no blood may appear because the soft catheter walls collapse during siphoning
what do if theres leakage and its hard to find source
o If leakage occurs locate the source. If leakage cant be stopped slow infusion rate as much as possible without stopping it and replace the tubing with a new sterile set. Estimate the amount of solution lost
infiltration
how often do you assess for it
what do if it happens
Inspect the insertion site for fluid infiltration at least every hour
o When dislodged it causes swelling in interstitial tissues=infiltration=localized swelling, pallor, coolness, discomfort
o If infiltration is present stop and restart elsewhere
o Apply warm compress to site of infiltration
what is it called when infiltration involves a dessicant drug
what do
If infiltration involves a desicant drug (a drug that can cause tissue necrosis) its called EXTRAVASATION and can cause tissue injury or destruction
o In this case stop the drug immediately. Disconnect the tubing as cose to the catheter hub as possible and attempt to aspirate any drug remaining in the hub. If injectable antidote is avail then it should remain in place
o Notif
o Elevate affected arm-depending on the drug, heat or old therapy should be implemented
phlebitis
s/s
how often do you inspect for it
o I&P at least q8h
o Chemical injury can cause phlebitis and may arise from IV and some meds
o Signs and symp of phlebitis: pain, tenderness, erythema, warmth, swelling at IV site or palpable venous cord
o if phlebitis is detected discontinue the infusion and apply warm compresses to the venipuncture site as ordered and according to agency policy
what shoul you tel pt to monitor their IV for or report
inspect IV site for bleeding
o more likely to occur once catheter is removed from vein
o provide instruction such as the following to clients to maintain the infusion sstem
o avoid sudden twisting or tunring movements of arm w catheter
o avoid stretching or placing tension on the tubing
o try to keep the tubing from dangling below the level of the catheter
o notify a nurse if:
the flow rate suddenly changes or the solution stops dripping
the solution container is nearly empty
there is blood in the IV tubing
discomfort or swelling is exp at the IV site
which are indicators of vascular volume and which are indicators of interstitial volume 1 dependent edema 2. cap refill 3. distended neck veins 4. skin turgror
vascular=cap refill, neck veins
inter=dependent edema, skin turgor
if theres a fluid or electrolyte imbalance how might this affect behaviour or LOC
• Behaviour and loc. Restlessness and mild confusion-occurs w FVD or acid base imbalance. Dec LOC occurs w severe ECV deficit
if you had an IVI how would you initiate a new bag
Flush w NS. keep syringe attached.
maint sterility of end of connector and have ready for attachment of tubing
o Open infusion set,
o Removing appropriate end caps,
o Place roller clamp abt 2-5cm below drip chamber and move roller clamp to off position
o Remove protective sheath over IV tubing port on plastic IV solution bag or top of bottle
o Compress drip chamber Allow to fill ½-1/3
o Prime infusion tubing by filling w IV solution:remove protective cap on end of tubing and slowly open roller clamp to allow fluid to travel from drip chamber through tubing to needle adapter. Invert Y connector to displace air. Return roller clamp to off position after priming tubing filled w IV fluid. Replace protective cap on end of infusion tubing
o Be certain that tubings clear of air. Tap to dislodge
how would you secure a catheter (venous) to the skin
can use :transparent drsg
sterile gauze drsg
manufactured catheter stabilization device
make sure to stabilize catheter for both
for the sterile gauze drsg use a 2X2 gauze pad over insertion site and catheter hub
if another nurse has inserted IV what is the next step after venipuncture for you
while they are keeping catheter stable you can do a saline flush or begin a primary infusion by slowly opening slide clamp or Iv roller clamp
- secure catheter- (transparent, sterile gauze or manuf. catheter stabilization device)
- apply sterile drsg over site (transparent drsg or sterile gauze drsg)
- loop the tubing and tape again
- maybe put into EID or set drip rate
- label drsg
- teach pt how to move w.out dislodging IV
what to label on new IV
date and time of IV insertion, VAD gauge size and length, initials
how do you apply transparent drsg (sterile) over new IV site
what should you avoid with this and why
- remove adherent back
- apply one edge and smooth it on
- leave connection bet IV tubing and catheter hub exposed
- take 1 inch of tape and place over admin set tubing but DONT TAPE THE DRSG. the tape stops moisture from being carried away from skin
how to apply sterile gauze drsg over IV site
2x2 over insertion site and catheter hub. secure edges w tape
- dont cover connection bet IV tubing and catheter hub
- place 2x2 thats folded and covered in tape under the catheter (this prevents P on skin)
is routine site or drsg care performed on short peripheral catheters?
no uness the drsg is soiled and no longer intact
what is an early sign of phlebitis that you can discern from palpation
tenderness when palpating the insertion site
phlebitis scale is scored from _ to _ which is worst
0-4 with 4 being worst
phlebitis of 0=
0-no symptoms
phlebitis
1-erythema at access site w or wout pain
2pain at access site w erythema and or edema
3-pain at access site w erythema and or edema. Streak formation. Venous cord.
4-pain at access site w erythema and or edema. Streak formation. Palpable venous cord >1 inch in length. Purulent drainage.
phlebitis you have pt w streak formation and venous cord, erythema, edema
what would they be on scale
3
what does 4 on phlebitis scale have that 3 doesnt
purulent drainage, venous cord is >1inch in length
which phlebitis score has erythema without pain
1
what do if FVD as evidenced by : dec urine output, dry mucous memb, dec cap refill, disparity in central and peripheral pulses, tachycardia, HoTN, shock
notify the dr
readjust infusion rate
what do if FVE crackles in lungs, SOB, edema
dec IV flw rate if symptoms appear
notify dr
Imbalanced electrolytes, changes in mental status, alterations in neuromuscular fxn, cardiac arrhythmias, changes in VS
notify dr
adjust additives in IV or type of IV fluid per order
Infiltration indicated by slowing of infusion; insertion site is cool to touch, painful, pale
stop infusion and d/c IV
elevate
restart new IV above site or other side
document degree of infiltration and nursing intervention
phlebitis what do p and p
stop infusion immed and d/c IV restart if nec higher or on opp arm warm moist compress monitor 48hrs document degree of phlebitis and nursing interventions
bleeding at site
Verify that system is intact and replae dressing if loosened
Restart new IV if bleeding from site doesn’t stop or if IV is dislodged
IV site infection: monitor site for redness, swelling, warmth, pain, edema, induration, temp and drainage
Notify health care provider for appropriate interventions such as culturing of device or site
Restart new IV if continued IV therapy is nec in area above location or opposite extremity
Document presence and severity of infection and interventions
what affects IV infusion rate
hanges in the pt position, flexion of the IV site extremity, and occlusion of the IV device influence infusion rates
o Vasospasm, venous trauma, or manip of the evice affects infusion rates
EIDs
why are they so useful
maint correct flow rates and catheter patency
prevent unexpected bolus of IV infusion
often record the amount of fluid infused
EID how does it work
uses positive pressure
will your pump tell you if youre giving a fluid at a setting that doesnt match the admin guideline
yes
example of a non EID
affected by
volume control device (delivers small volumes)
o Pt and mech factors (height of the IV fluid controller, IV tubing size, or fluid viscosity) affect an Iv gravity controller). Eg calibrated chamber bet the IV container and the insetion spike and drip chamber of an admin set
microdrip is _ drops an hour. it is used for delivery of what how many mls an hour
macro is __
micro is 60 gtt an hr for rates 100ml/hr
when determining how long each liter of fluid should run how do you calc
eg 100ml over 8 hrs
or 3000ml over 24hr
ml/hr=total infusion in ml divided by hours of infusion
Ml/hr=total infusion (ml)/Hours of infusion
1000ml/8hr=125ml/hr
or if 3000ml is ordered for 24hrs 3000ml/24hr=125ml/hr
formula for calculation of drops per minute or minute flor rate
ml/hr/60min=ml/min
drop factor x mL/min=Drops/min
or
ml/hr x Drop factor/ 60min= Drops/min
calc minute flow rate for microdrip : 1000ml at 125ml/hr
125ml/hr x 60gtt/ml=75000gtt/hr
75000gtt/60min=125ml
calc minute flow rate macrodrip of 1000ml at 125ml/hr
125ml/hr x 15gtt/ml=1875gtt/hr
1875gtt/60 minutes=31-32gtt/min
if using a gravity infusion how high above Iv site do you want the Iv container (adult)
how do you set it
36 inches
confirm hourly rate and minute rate based on drop factor
reg flow rate w watch watching for 1 minute and adjusting roller clamp
how to use EId for infusion
o For Eid insert IV tubing into chamber of control mechanism-most use positive prssure
o Turn on, select required drops er hr, press start
o Open drip regulator completely while EId is in use
o Monitor infusion rate and IV site for omplications according to agency policy. Use watch to verify rate of infusion even when using EID
o When alarm sounds test patency (alarm may be set off by empty solution container, tuing kinks, closed clamp, infiltration, clotted catheter, air in the tubing, and or low battery
volume control device
where is it placed
how much fluid goes in (timeframe)
if it runs out will it stop
For volume control devices
o Place volume control device bet Iv container and insertion spike of infusion set using aseptic technique
o Place no more than a 2hr allotment of fluid into device by opening clamp bet IV bag and deviceallows for continuous infusion of fluid if you don’t return in exacl 60 mins to refill volume. IF infusion rate accidentally inc, pt receives only a 2hr allotment of fluid.
o Assess system at least hourly; add fluid to volume control device. Refulate flow rate
o Instruct pt in purpose of alarms, to avoid raising hand or arm that affet flow rate and to avoid touching control clamp
what do if Sudden infusion of lg volume of solution occurs w pt having symptoms of dyspnea; crackles in lung; and inc urine output, indicating fluid overload
Slow infusion rate: KVO rates must have specific rate ordered by licensed independent practitioner Notify immed
high Fowlers
anticipate new IV orders
admin diuretics ordered
Iv fluid container empties w subsequent loss of IV line patency
Discontinue present IV and restart new short peripheral catheter in new site
what to record at shift change r/t IV
o At shift change or going on break report rate of and volume left in infusion to nurse in charge or next nurse assigned to care for pt
IV considerations kids
what equipment do they use
o Total body weight=85-90% water
o Dehydration is a common cause of fluid and electrolyte imbalance
o To ass fluid needs use meter square weight or caloric method
o Infusion pumps are almost always used in peds as they give sm amounts of fluids and accurately provide the prescribed volume of IV solution
o Microdrip tubing isn’t recommended
o Only sm volume containers for infusions
o 250ml for infants-12months
o 500ml for older kids
older adult equipement and IV considerations
o Renal changes & cardiac issues, dec blood flow=easier to dehydrate or fluid overload
o Use EID and microdrip tubing to admin fluids
o Monitor electrolyte levels, BUN, creatinine, urine output, daily weight
o Some easily dev cerebral edema from rapid dextrose infusions
o Those w impaired renal fx often dev hypernatremia from NS infusions
when shoud next IV bag be ready for a change
an hr before it will empty. change it when theres 50ml left
what can you do if your drip chamber is too full
o Ensure drip chamber is 1/3-1/2 full. If too full level can be dec by removing bag from IV pole pinching off tubing below drip chamber, releasing and turning solution container upright and releasing pinch on tubing
how do you label a newly hung bag
o Place time label w time hung, time of completion, and appropriate intervals. If using plastic bags, mark only on label and not container
if youve accidentally given >
NOTIFY IF PTS ANTICIPATED INFUSION IS 100-200ML LESS THAN OR GREATER THAN ANTICIPATED
what is an intermittent infusion device used for
o Intermittent infusion devices are used to main venous access wout continues fluid infusion
what is KCL
consideration
o KCL=potassium chloride. Its measured in milliequivalents per litre and is high alert
