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o Catheter or tube irrigants-fluids used to irrigate NG tubes if not immediatel withdrawn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
