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Nursing skills 2 > Fluids > Flashcards

Fluids Flashcards

1
Q

Fluid therapy

A

 Maintain body water (patient can’t drink)
 Replace body water (patient is dehydrated/bleeding)
 Maintain blood pressure (anesthesia, shock, …)
 Diuresis (toxins, overdose)
 Other
 Vehicle to deliver drugs
 Electrolyte correction
 Parenteral nutrition
 Blood or blood product transfusion

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2
Q

Per os fluid administration

A

 Drinking
 Preferred
 Largest volumes
 Closest to nature
 Limitations
 Works if mild dehydration
 Patient must be conscious
 No vomit – Will make it worse
 No diarrhea – Won’t absorb

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3
Q

Iv fluids

A

 Fastest
 Large volume
 Status of patient does not matter
 Only choice if severely dehydrated, shock
 Can use to deliver drugs, electrolytes, nutrition
 Limitations
 High cost, technical
 Hospitalized
 Requires venous access

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4
Q

Subcutaneous fluids

A

 Under the skin
 Most common in small animals –> Cats
 Volume is limited by skin physiology
 Cats have less SQ attachment so more room
 Dogs have more attachment so less room
 Practical, fast, lower cost

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5
Q

Administering SQ fluids

A

 Aseptic technique
 Alcohol swab injection port on IV bag
 Discard needles after each use
 Generally only 0.9% NaCl or lactated ringers (LRS)
 Maximum volume is 100 ml/day cat
 Give 50 ml twice; or split into 2 (or more) sites once

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6
Q

Intraosseous fluids

A

 Into the medullary canal of a long/large bone
 Tibial tuberosity, trochanteric fossa of the femur, wing of ilium, greater tubercle
 Most common in exotics and neonates
 Technical
 Requires aseptic technique due to high risk of
osteomyelitis
 Treat similar as IV administration
 Volumes, type of fluid, fluid rate
 Short term only

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7
Q

Maintenance volumes

A

 The amount of water (fluid) intake required for basic functions in a healthy individual
 Some variation depending on source of information
 Varies with
 Species
 Size of animal
 Age (pediatric require more fluid)
 Health status (cardiac and renal most important

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8
Q

Deciding rates and volumes

A

 The rate is an order by the DVM
 “Maintenance/pediatric/surgical/shock rate”
 “Replace % or mls dehydration”
 The total amount given is an order by the DVM
 Hours of therapy
 Total volume to be infused (VTBI)
 How it is administered is determined by the RVT
 Convert order to ml/h
 Convert to drip rate
 Start and stop times

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9
Q

Prescribed rate

A

Fluid administration rate ordered by the DVM
 Expressed as ml/kg/h in small animals
 Expressed as L/kg/h in large animals

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10
Q

Infusion rate

A

The rate at which fluids are administered
 Determined from prescribed rate
 Expressed as ml/h in small animals
 Expressed as L/h in large animals
 How rates are entered in the medical record

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11
Q

Drip rate

A

The rate of fluid administration expressed as drops/sec or drops/min when using a drip-set
 Specific to the size of the drip-set being used
 Must be whole drops
 Not usually entered in the medical record

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12
Q

Delivery rate

A

The number of calibrated drops of fluid that make up 1 ml of fluid
 Expressed as drops/ml
 Must be whole drops

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13
Q

Infusion time

A

The total time over which fluids are administered
 Expressed in hours

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14
Q

Volume infused

A

The total volume of fluid administered
 Expressed in mls or liters
 Infusion rate x infusion time
 Also “volume to be infused (VTBI)”, “infusion volume”

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15
Q

IV drip administration

A

 Simplest form of IV fluid administration
 Uses gravity
 Supplies
 IV fluid bag (50 ml to 1 L, select based on patient size)
 IV infusion set (primary drip set)
 Extension set (optional*)
 Sterile needle
 Fluid stand
 Tape
 Permanent marker
 Clock or watch with second hand
 IV catheter in patient

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16
Q

IV infusion set

A

 Primary drip set, drip set
 Macro (regular) size: 10, 15 or 20 drops/ml
 Micro (pediatric) size: 60 drops/ml
 Rough guideline
 Select a macro drip if >10 kg and/or >100 ml/h
 Select a micro drip is <10 kg and/or < 100 ml/h
 Easiest to count between 1 drop/sec to 1 drop/4 sec

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17
Q

Troubleshooting fluid rates

A

 Roller clamp has variable quality/accuracy
 Long-term use wears plastic so flow rates may change
 Flow rate changes with any change in vertical distance between bag and patient; and with positioning of line
 Moving patient up or down
 Moving bag up or down
 Moving patient around
 Maximum flow rate is limited by the size of the infusion set AND the gauge of the IV catheter

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18
Q

Moving a patient on IV fluids

A

 When using a drip set:
 Rate of flow is determined by difference in height between the fluid bag and the patient
 Height will change when patient is moving this will alter flow rate
 ALWAYS turn off fluids infusion when patient is being moved
 ALWAYS re-set and confirm drip rate when patient stops moving
 Moving a patient while fluids are running risks fluid overload

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19
Q

Stopping fluid infusion

A

 Moving patient (moving from induction to OR; moving from OR to recovery); OR if no extension set
 Close slide clamps at 2 sites if possible:
1. Closest to patient
2. Closest to fluid bag
 Longer periods (bathroom, walks, x-ray) where patient is stable enough to be off fluids; and where there is an extension set
 Turn off flow
 Close slide clamps
1. Closest to patient
2. Closest to connector (on both sides of the connecter)
 Extension set stays with patient
 Disconnect and cap off both ends to maintain sterility
 Wrap extension set against patient’s leg with vetwrap
 When reconnecting the IV fluids, check catheter has not clotted or displaced
 Check by flushing

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20
Q

Y-injection ports

A

 Where medication or other fluids can be injected to be infused into the patient
 Needle-ports
 Needle-free ports (clave connectors)
 ALWAYS wipe port with alcohol before each use

21
Q

IV push or bolus

A

 Giving a medication intravenously in one-shot (not over an extended period of time)
 Can inject medication into an injection port in the IV line
 Still given over 30 seconds up to 1 minute
 Dependent on volume to be given
 Decreases how quickly the drug reaches its peak concentration anywhere in the body
 This decreases risk of adverse drug effects:
 Toxicity
 Anaphylaxis
 Overdose
 Must flush line to get into patient

22
Q

Slow IV

A

 One-shot of medication given over 10 – 20 minutes
 These drugs have more toxicity so the goal is to prevent a sudden spike
 Toxic effects if given faster

23
Q

Infusion pump

A

 Aka volumetric pump
 Force fluid into the vein under pressure
 Does not depend on gravity
 Consistent, accurate
 Must enter infusion rate: ml/hr
 Range is usually 1 ml/h to 999 ml/h
 Note: takes 5 ml/h to keep vein open
 Some models have a VTBI – will turn off after desired volume infused
 Problems:
 Risk of infiltration if catheter displaces and forces fluid into tissues
 May not alarm if problems so must check regularly
 Occlusion = line is blocked or flow is blocked

24
Q

Volume controlled burette

A

 Gravity based
 Place between IV bag and patient
 Used for greater accuracy in
1. Measuring smaller volumes
2. Delivering medications
 100-150 ml chamber size
 1 ml increments
 Chamber filled to desired amount from primary bag
 Medication injected into port
 Desired rate set manually (drip chamber) or with pump
 Previous slide shows “flow-
through” set-up
 Photo on right shows proper
way to hang burette if full
VTBI is contained in burette
 Burette MUST be perpendicular
to ground

25
Flow regulators
 Component that is part of an infusion set or can be added as an extension set  Provides constant infusion rate to patient  Works by controlling size of opening  5 ml/hr to 250 ml/h  Gravity sets only  No drips to count  Single use only
26
Secondary IV
 Purpose:  Increase the amount of reservoir fluids  To deliver an intermittent medication or second type of fluid  Each bag has its own drip chamber so can set independent flow rates  Second bag of fluid is placed higher than the primary bag  Higher bag will empty first, when it is done, primary bag will then flow  Requires a specific piggy-back infusion set that connects with a Y-port
27
In line filters
 Precision filters  Openings as small as 0.2 μm  Placed in-line  Depending on type of filter, can remove air, particulate matter  Blood transfusion sets have 160-270 μm filters to remove small clots and clumps due to storage
28
Syringe pump
 Purpose: To deliver small volume of fluid (placed in the syringe) at a constant rate over given period of time  Volume determined by size of syringe  Used for 1. Medications that cannot be diluted into an IV bag 2. Fluid delivery into very small patients
29
CRI
 Continuous rate infusion  Dosing regiment used to deliver a constant amount of drug per unit time  Usually ml/kg/hr; can be as little as microliters (μl) per min  Most commonly by IV infusion  Drip rate is an example  Syringe pump delivery is an example  Can also be by transdermal delivery (e.g., patches)
30
After adding drug to an IV line
 After the medication has been administered, flush the line with 3-5 ml of 0.9% saline or LRS (enough to clear the medication from the line). Give at the same rate the medication was administered.  Also need to flush a burette if using to administer a medication. Volume should be at least 2x the amount of dead space in the tubing between the burette and the patient. Give at same rate as drug was administered.
31
IV fluid types
 All IV fluids are solutions consisting of solutes that are dissolved in water  Composition varies, but in general contain:  Water  One or more electrolytes  Na+, Cl-, K+, Mg+  Buffer to regulate pH  lactate, bicarbonate, gluconate, acetate, phosphate  Colloids – Large molecular weight molecules  Dextrose for nutrition
32
IV fluid classifications
Based on relation to osmotic pressure  Isotonic – same osmolarity as plasma  Hypotonic – significantly less osmotic pressure than plasma  Fluid leaves veins and enters tissue  Hypertonic – significantly greater osmotic pressure than plasma  Fluid enters veins from tissue  Balanced versus unbalanced  Balanced fluids have a profile similar to extracellular fluid (ECF)  High concentration Na+, Cl- and bicarbonate  Unbalanced fluids - Profile is not similar to ECF
33
IV fluids based on functional use
 Replacement fluids  Higher levels Na+ and Cl-  Intended for replacing lost body water or short-term use  Maintenance fluids  Lower Na+ and Cl-, higher K+  Intended for long-term use  Other – flush, hypertonic saline...
34
IV fluids based on molecular weight
Crystalloid Colloid Blood and blood products
35
Crystalloids
 Most common for maintenance and surgical fluids  Physiological saline (0.9% NaCl) mostly for flushes, flushing wounds and body cavities, can be used for replacement  LRS, Normosol, Plasmalyte, physiological saline with 20 mEq KCl
36
Colloids
 Large molecular weight solutes that cannot cross out of blood vessels  Supports oncotic pressure; draws water out of interstitial space and into blood vessels  Only used if crystalloids are not sufficient to maintain BP  Fluid selection is up to the VIC; based on each patient  Must record fluid type, rate, total volume (or start and stop times), any changes in fluid rate as they occur
37
Crystalloids are
 Water + small molecular weight solutes  Electrolytes  Na+, Cl-, K+, Ca+, Mg+  Very high levels of Cl- compared to plasma  Buffers  phosphate, lactate, bicarbonate, acetate, gluconate  +/- Dextrose  Molecules are small enough to pass in and out of the blood vessels  Generally used for flushing, replacement and maintenance  Often used in anesthesia patients  Unless they are anemic or have severe hypotension  5 basic types of crystalloid
38
Replacement solutions
 Isotonic - Osmolarity similar to plasma  Polyionic - Contains multiple electrolytes and buffers  Balanced – Similar to ECF  Indicated for restoring hydration, correcting hypotension, replacing electrolytes  Can be used for short-term maintenance  Need to check electrolytes q24h  Reminder: high in Na+ and Cl-; low in K+  Common examples  Lactated Ringer’s Solution* (LRS)  Normosol-R (NR)  PlasmaLyte A and R* (PA and PR)  Isolyte S (IS) * LRS and PR contain calcium and cannot be administered with blood products
39
Maintenance solutions
 Compared to replacement solutions:  Contain less Na+, less Cl-  Contain more K+  Contain lower concentrations of buffers  May contain dextrose  Indicated for long-term use  Unlike replacement fluids, will not cause hypernatremia and hypokalemia over time  Common examples  Normosol-M (NM)  PlasmaLyte 56 (PL56)
40
Dextrose containing solutions
 Maintenance solutions may contain dextrose  Commonly available as 5% solution (5g/100 mL)  Can also purchase as 50% w/v solution in water to add to an IV bag  Only give dextrose solutions IV  Indicated for parenteral nutrition  Hypoglycemia, neonates, diabetics, severely debilitated (cachexic)  Common examples  LRS + 5% dextrose (D5LR)  Plasma-Lyte 56 with 5% dextrose (PL56D5)
41
Normal saline
 Physiologic saline, 0.9% saline, NaCl 0.9%  Only contains sodium and chloride dissolved in water  Isotonic, buffered to physiologic pH  Indicated for  Flushing IV catheters  Flushing wounds  Bathing tissues or body cavities during surgery  Sometimes used in place of replacement solutions – may require addition of potassium
42
Hypertonic saline
 Concentrated NaCl solution – 3%, 5%, 7% and 23.4%  Injection into vein creates very large osmotic gradient  Water moves from ECF into the intravascular space  Indicated for  Severe hyponatremia  Managing severe hemorrhage or hemorrhagic shock  Fast-acting, low-volume resuscitation (hypovolemic shock)  Treating high intracranial pressure  Contraindicated in hypernatremia, severe dehydration  Seldom used
43
Colloids are
 Contain large molecular weight solutes  Usually starch molecules too big to leave the blood vessels  Molecules increase oncotic pressure in blood vessels  Draw water into vessels  Indicated for  Hypotension and large volume losses (when crystalloids are not enough)  Low total protein (TP < 35 g/L)  Examples of synthetic colloids:  Hetastarch  Dextran
44
Blood and blood products
 Includes whole blood, RBC concentrate, platelet extract, plasma  Plasma contains albumin which is considered a “natural colloid”  Indication depends on type of product being used  Hemorrhage  Anemia  Bleeding disorders  Hypoproteinemia  Very expensive, can be hard to access, risk of adverse reaction
45
Volume overload
 Aka over-hydration  Can occur from too much fluids OR too fast fluids  Giving fluids too fast prevents them from entering into the extracellular fluid volume properly  Physiological effects of volume overload  Hypertension  Very bad if pre-existing heart disease; causes heart to work harder and can cause cardiac overload  Fluids move to 3rd spaces in the body  Abdomen, pleural space, pulmonary spaces  Most common is pulmonary edema  Can also cause cerebral edema  Can dilute oxygen carrying capacity of blood
46
Signs of volume overload
 Increased lung sounds and respiratory rate  Dyspnea  Coughing and restlessness if patient is awake  Tachycardia – why?  Increased BP  Hemodilution (decrease the relative PCV)  Ocular and nasal discharge  Chemosis  Subcutaneous edema  Neurological signs Response to volume overload 1. Reduce infusion rate 2. Give diuretics * Furosemide given IV acts in 5 minutes * Causes diuresis (i.e., promotes urination)
47
Who is most at risk for volume overload
Most at risk for volume overload:  Cardiovascular patients  HCM, heart failure, mitral valve insufficiency, hypertension  Renal failure patients  Patients <5 kg  Patients that are already anemic  Can affect the oxygen carrying capacity of the blood  Patients that are hypoproteinemic  Already have lower oncotic pressure  So fluid more likely to leave the blood vessels
48
Preventing volume overload
 Know your calculations!  Use an appropriate-sized fluid bag  ex. 100 ml for cat spay  Clamp off the line when transporting patients  Check IV line and rate hourly  Caution: most drip sets will alter their rate slowly over time  Use an infusion pump  Monitor equipment  Monitor patient  Use IV fluids when monitored and SQ fluids if not monitored
49

Nursing skills 2 (4 decks)

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