clinical meas of fluid/electrolyte balance

Question 1

3 clinic measurements nurse can initiate regarding fluid balance

Answer 1

weights,
fluid intake/output,
vital signs

Question 2

each kg of fluid lost is equal to how many litres

what is an acute change in weight

Answer 2

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

Question 3

how do vitals change in response to fluid imbalances or lyte imbalance

Answer 3

• 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

Question 4

how do you assess orthostatic hypotension

Answer 4

• 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

Question 5

how to record intake

what is put on the balance

Answer 5

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o Catheter or tube irrigants-fluids used to irrigate NG tubes if not immediatel withdrawn

Question 6

fluid output. what is recorded

Answer 6

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

Question 7

when do you total i and o

how do you know if they match up

Answer 7

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

Question 8

o Inc in serum osmolarity indicates what

Answer 8

fluid volume deficit

Question 9

what does an inc in urine specific gravity indicate

how would it be in FVE vs FVD

Answer 9

o When conc of solutes in urine is high (FVD) the specific gravity rises when conc is low FVE the specific gravity is low

Question 10

romoting healthy fluid and elextrolyte balance (instructions for pts)

Answer 10

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

Question 11

which solns are isotonic

Answer 11

Isotonic solutions:
0.9% sodium chloride (NS),
Lactated Ringers or
Ringer’s solution

5% dextrose in water

Question 12

what occurs w isotonic solns
what do you assess for them
what are they used for

Answer 12

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

Question 13

which isotonic soln is electrolyte balanced

Answer 13

Ringer’s is physiologic (electrolyte) balanced.

Question 14

which isotonic soln must you be wary of liver fx and why. what is this soln given for

Answer 14

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

Question 15

D5W iso, hypo, hypertonic once in the plasma? what is it used for and contraindicated for?

Answer 15

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

Question 16

eg of hypotonic soln

Answer 16

0. 45% NaCl half normal saline,
1. 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

Question 17

considerations for hypotonic solns

Answer 17

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

Question 18

egs hypertonic solns

Answer 18

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)

Question 19

cosiderations for admin of hypertonic solns

Answer 19

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?

Question 20

nutrient solutions good for and not good for

examples

Answer 20

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

Question 21

some examples of acidifying solns

Answer 21

o Acidifying solutions are 5% dextrose in 0.45% sodium chloride and 0.9% sodium chloride solution

Question 22

volume expanders
eg
fx

Answer 22

Volume expanders
o Solutions used to inc the blood volume followig blood loss or loss of plasma
o Eg albumin and human serum albumin

Question 23

when is butterfly IV most often used

Answer 23

for short term use (

Question 24

how long are IV catheters

Answer 24

o A peripheral short catheter is less than or equal to 7.6cm in length

Question 25

how should catheters be stabilized

Answer 25

no longer w tape. now w manufactured catheter stabilization device

Question 26

when would a glass bottle be used with an IV considerations for this

Answer 26

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

Question 27

what would cause you to return the iv soln bag and not use it

Answer 27

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

Question 28

_________is kept sterile and inserted into the solution container when the equipment is set up and ready to start

Answer 28

insertion spike

Question 29

if you dont need continuous infusion but you may want to have venous access in the future what do

Answer 29

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)

Question 30

Iv filters fx | problems that can arise

Answer 30

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

Question 31

before prepping an IV infusiont he nurse shoud

Answer 31

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

Question 32

flow rates above what should be assessed every 15-30min

Answer 32

150ml/hr

Question 33

in order to monitor an IV infusion what pertinent data do you need

Answer 33

o Gather pertinent data: type and sequence of solutions to be infused, determine the rate of flow and infusion schedule

Question 34

you go to ensure that the correct solution is being infused and its not the right one. what do

Answer 34

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

Question 35

if an IV rate is too slow or too fast can you change it if it were infusing too fast what would you assess

Answer 35

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

Question 36

how could you manipulate the catheter and bag to det if it is still in lumen

Answer 36

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

Question 37

what do if theres leakage and its hard to find source

Answer 37

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

Question 38

infiltration how often do you assess for it what do if it happens

Answer 38

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

Question 39

what is it called when infiltration involves a dessicant drug what do

Answer 39

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

Question 40

phlebitis s/s how often do you inspect for it

Answer 40

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

Question 41

what shoul you tel pt to monitor their IV for or report

Answer 41

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

Question 42

``` 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 ```

Answer 42

vascular=cap refill, neck veins | inter=dependent edema, skin turgor

Question 43

if theres a fluid or electrolyte imbalance how might this affect behaviour or LOC

Answer 43

• Behaviour and loc. Restlessness and mild confusion-occurs w FVD or acid base imbalance. Dec LOC occurs w severe ECV deficit

Question 44

if you had an IVI how would you initiate a new bag

Answer 44

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

Question 45

how would you secure a catheter (venous) to the skin

Answer 45

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

Question 46

if another nurse has inserted IV what is the next step after venipuncture for you

Answer 46

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

Question 47

what to label on new IV

Answer 47

date and time of IV insertion, VAD gauge size and length, initials

Question 48

how do you apply transparent drsg (sterile) over new IV site | what should you avoid with this and why

Answer 48

- 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

Question 49

how to apply sterile gauze drsg over IV site

Answer 49

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)

Question 50

is routine site or drsg care performed on short peripheral catheters?

Answer 50

no uness the drsg is soiled and no longer intact

Question 51

what is an early sign of phlebitis that you can discern from palpation

Answer 51

tenderness when palpating the insertion site

Question 52

phlebitis scale is scored from _ to _ which is worst

Answer 52

0-4 with 4 being worst

Question 53

phlebitis of 0=

Answer 53

 0-no symptoms

Question 54

phlebitis

Answer 54

 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.

Question 55

phlebitis you have pt w streak formation and venous cord, erythema, edema what would they be on scale

Answer 55

3

Question 56

what does 4 on phlebitis scale have that 3 doesnt

Answer 56

purulent drainage, venous cord is >1inch in length

Question 57

which phlebitis score has erythema without pain

Answer 57

1

Question 58

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

Answer 58

notify the dr | readjust infusion rate

Question 59

what do if FVE crackles in lungs, SOB, edema

Answer 59

dec IV flw rate if symptoms appear | notify dr

Question 60

Imbalanced electrolytes, changes in mental status, alterations in neuromuscular fxn, cardiac arrhythmias, changes in VS

Answer 60

notify dr | adjust additives in IV or type of IV fluid per order

Question 61

Infiltration indicated by slowing of infusion; insertion site is cool to touch, painful, pale

Answer 61

stop infusion and d/c IV elevate restart new IV above site or other side document degree of infiltration and nursing intervention

Question 62

phlebitis what do p and p

Answer 62

``` 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 ```

Question 63

bleeding at site

Answer 63

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

Question 64

IV site infection: monitor site for redness, swelling, warmth, pain, edema, induration, temp and drainage

Answer 64

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

Question 65

what affects IV infusion rate

Answer 65

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

Question 66

EIDs | why are they so useful

Answer 66

maint correct flow rates and catheter patency prevent unexpected bolus of IV infusion often record the amount of fluid infused

Question 67

EID how does it work

Answer 67

uses positive pressure

Question 68

will your pump tell you if youre giving a fluid at a setting that doesnt match the admin guideline

Answer 68

yes

Question 69

example of a non EID | affected by

Answer 69

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

Question 70

microdrip is _ drops an hour. it is used for delivery of what how many mls an hour macro is __

Answer 70

micro is 60 gtt an hr for rates 100ml/hr

Question 71

when determining how long each liter of fluid should run how do you calc eg 100ml over 8 hrs or 3000ml over 24hr

Answer 71

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

Question 72

formula for calculation of drops per minute or minute flor rate

Answer 72

ml/hr/60min=ml/min drop factor x mL/min=Drops/min or ml/hr x Drop factor/ 60min= Drops/min

Question 73

calc minute flow rate for microdrip : 1000ml at 125ml/hr

Answer 73

125ml/hr x 60gtt/ml=75000gtt/hr | 75000gtt/60min=125ml

Question 74

calc minute flow rate macrodrip of 1000ml at 125ml/hr

Answer 74

125ml/hr x 15gtt/ml=1875gtt/hr | 1875gtt/60 minutes=31-32gtt/min

Question 75

if using a gravity infusion how high above Iv site do you want the Iv container (adult) how do you set it

Answer 75

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

Question 76

how to use EId for infusion

Answer 76

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

Question 77

volume control device where is it placed how much fluid goes in (timeframe) if it runs out will it stop

Answer 77

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

Question 78

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

Answer 78

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

Question 79

Iv fluid container empties w subsequent loss of IV line patency

Answer 79

Discontinue present IV and restart new short peripheral catheter in new site

Question 80

what to record at shift change r/t IV

Answer 80

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

Question 81

IV considerations kids | what equipment do they use

Answer 81

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

Question 82

older adult equipement and IV considerations

Answer 82

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

Question 83

when shoud next IV bag be ready for a change

Answer 83

an hr before it will empty. change it when theres 50ml left

Question 84

what can you do if your drip chamber is too full

Answer 84

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

Question 85

how do you label a newly hung bag

Answer 85

o Place time label w time hung, time of completion, and appropriate intervals. If using plastic bags, mark only on label and not container

Question 86

if youve accidentally given >

Answer 86

NOTIFY IF PTS ANTICIPATED INFUSION IS 100-200ML LESS THAN OR GREATER THAN ANTICIPATED

Question 87

what is an intermittent infusion device used for

Answer 87

o Intermittent infusion devices are used to main venous access wout continues fluid infusion

Question 88

what is KCL | consideration

Answer 88

o KCL=potassium chloride. Its measured in milliequivalents per litre and is high alert