IV Therapy Flashcards
In older adults, what is not a good predictor of fluid deficits?
diminished skin turgor
Why does the patient experience cold, clammy skin in hypovolemia?
adrenalin shunts blood flow away from periphery to vial organs
What are the danger signs for fluid deficit (HYPOVOLEMIA)? - 8
- restlessness (1st clue), confusion … coma
- cold, clammy skin
- decrease skin turgor (tenting)
- weak, rapid heart rate
- rapid respirations: hypoxia
- orthostatic hypotension: fall precaution
- Oliguria: decrease urine output due to poor perfusion to kidneys (concentrated)
- decrease cap refill, flat jug veins, weight loss
How can a pulmonary edema occur with dyspnea/tachypnea?
Left ventricle overloads - pumping declines - fluid backs up in the lungs - hydrostatic pressure pushes fluid out of pulmonary vessels and into interstitial and alveolar areas - pulmonary edema
What are the danger signs of fluid excess? (HYPERVOLEMIA)
- HA, confusion
- peripheral edema
- jugular vein distension
- Extra heart sound (S3)
- bounding pulse, increase bp
- dyspnea, tachypnea, crackles
- pink frothy sputum = pulmonary edema
- weight gain
What is a hallmark of pulmonary edema in hypervolemia?
pink, frothy sputum
Fluid imbalances are more prominent in what age group?
young and the old
Nursing Management of a fluid imbalance
- Assess for S/S of imbalance (At - risk)
- Give IV fluids and meds as ordered (if deficit)
~ If excess, then restricted fluids
~ If deficit, give isotonic and oral fluids - O2 Therapy for both
- Fall precautions
- Daily weight Accurate
- I&O accuracy
- Elevate edematous extremities
- Encourage fluids if at a deficit = monitor at-risks
When patients have GI losses, hemorrhage, overuse of diuretics, inadequate fluid intake, and third space shifting, what are they at risk for?
Fluid deficit
When patients have of heart failure, renal failure, excess isotonic or hypotonic fluids, SIADH, or long-term steroids, what are they at risk of?
Fluid excess
Hypovolemic Shock occurs when
- Common signs
40% more of intravascular volume is lost
- loss of LOC, cardiac output, urine below 10mL/h
Treatment of hypovolemic shock
- fluid replacement NS, LR to expand volume; blood transfusion; vasopressor
- lower HOB to slow declining bp
- 2 large bore IV catheters
- O2 therapy
- monitor VS and LOC
- lung sounds for crackles (fluid buildup in lungs = f;uid overload)
- indwelling catheter possible for output
Vasopressor
group of medicines that contract (tighten) blood vessels and raise bp
- used to treat severely low bp
Why does the body decrease in BP during hypovolemia?
~Heart baroreceptors notice a decrease in fluid volume and **posterior pituitary secretes VP
- VP increases vasoconstriction and water absorption from filtration
~ Glomerulus activate RAAS
- increase in angiotensin 2, aldosterone, vasoconstriction, VP, drinking
- aldosterone increases sodium retention
What is the difference between hypovolemia and dehydration?
Dehydration is water loss alone
Hypovolemia is the volume (water and concentration) lost
In summary, hypovolemia is when ____________ fluid is __________; this results in decreased tissue __________.
Extracellular; reduced: perfusion
- produced by salt and water loss from the extracellular fluid
What are the 5 signs of dehydration?
- feeling thirsty
- dark yellow and strong-smelling pee
- peeing little, and fewer than 4 times a day
- feeling dizzy and tired
- dry mouth, lips, and eyes
Dehydration
water loss alone with Na concentration goes high
- pure water loss from total (only 1/3 of ECF)
ALWAYS HYPERNATREMIC - high sodium
Treat with free water administration
IV Therapy
Where?
Length?
Absorption?
within the vein (peripheral or central)
short to long term
Fastest delivery method
IV Therapy Advantages
- replace fluid
- transfuse blood
- deliver meds
- correct electrolyte imbalances
IV Therapy Disadvantages
- adverse reactions
- incompatible
- infections (local or systemic)
-damage
-fluid overload
-overdose - hinderance (annoying)
- potentiate/worsen electrolyte imbalances
Larger insoluble molecules, such as gelatin or blood
Faster action for volume expansion and high osmotic pressures
are termed as
Colloids
Small molecules, inexpensive mineral salts, and water-soluble molecules are termed as
crystalloids
Isotonic Solutions Types
D5W - 5% Dextrose in Water
NS - 0.9% Sodium Chloride
LR - Lactated Ringers
Hypertonic Solutions include
D5 1/2 NS - 5% Dextrose 0.45% Sodium Chloride
D5NS - 5% Dextrose 0.9% Sodium Chloride
D5LR - 5% Dextrose Lactated Ringers
D10W - 10% Dextrose in Water
What isotonic solution can metabolize into a hypnotic solution?
D5W
use with caution bc once metabolized becomes hypotonic
Isotonic solutions do what in the body?
remain in the intravascular compartment and don’t pull fluid from other compartments
- replace volume
What solution is used for issues with hypovolemia, resuscitation, shock, burn injuries, DKA, alkalosis, hypercalcemia, and mild sodium deficits?
Normal Saline
What is the only solution that can be given with blood or blood products?
Normal Saline
This fluid should not be used in patients with renal disabilities. Why?
Lactated Ringers, because contain potassium
What is used for acute blood loss and is a volume expander?
Lactated Ringers
What solution do you not want to give if the patient has a renal disability?
Lactated Ringers, because contains Na, K, Ca, Cl
Hypotonic solutions have
osmolarity lower than serum osmolarity
- use cautiously for at risk of intracranial pressure
When a pt receives hypotonic solutions, fluid shifts where?
shifts out of the blood vessels and into cells/interstitial spaces with high osmolarity
- cells swell
- hydrate cells while reducing fluid in the circulatory
Hypotonic Solutions Types
1/2, 1/3, 1/4 NS, and D2.5W
What percentage of body fluid is water?
60%
What “nutrient” is more important than other nutrients?
water
What are the purposes of water in the body? - 5
- transports nutrients and O2 to cells
- removes waste
- medium of electrolyte chemical reactions and digestion
- regulate body temp
- lubricates joints
Fluids in the body are affected by
-age
-gender
- body fat
What gender has more body fluid and why?
men; more muscle mass
What gender has a greater percentage of fat?
women
______ people have less fluid than those who are thin because fat cells contain little water
obese
The highest amount of water is found in
muscle, skin, and blood
What is the most accurate way to measure fluid status in a person?
Daily weight
Not I&Os
Filtration
movement of fluid across cell membrane due to hydrostatic pressure
Diffusion
movement of solutes (substances) from higher to lower concentration
Osmosis
movement of fluid (water) from areas of more fluid to areas of less fluid
- liquid through membrane from less concentrated to more concentrated one
What are the 3 mechanisms/processes that control fluid and solute movement to prevent dangerous changes?
Filtration
Diffusion
Osmosis
Hydrostatic pressure is generated by the ___________ system. How?
cardiovascular
- blood is pumped through the body’s blood vessels
In diffusion, what moves
**Fish swimming with the current
solutes
During osmosis, the body is attempting
homeostasis
What do these abbreviations mean?
DS
OF
In diffusion, solutes move
Osmosis, fluid moves
What is the purpose of a semi-permeable membrane in osmosis?
a type of biological or synthetic, a polymeric membrane that will allow certain molecules or ions to pass through it by osmosis.
What does osmotic balance mean?
the control of water and electrolyte balance in the body
Osmoregulation
active regulation of osmotic pressure of bodily fluids to maintain the homeostasis of the body’s water content
- keeps fluids from becoming too dilute or too concentrated
Hydrostatic =
pushing force fluid out of capillaries
exerted by pumping of heart
Normal movement of fluids through the capillary wall into the tissues depends on two forces:
Hydrostatic and oncotic
Capillaries get ________ the further away it gets from the heart.
smaller
Oncotic pressure
pulling force - pulls fluids from the tissue into capillaries
- exerted by non-diffusible plasma proteins - albumin
When hydrostatic pressure is greater than oncotic pressure, then
fluid will leave the capillaries, visa versa
On the arterial end of ________ pressure is higher than _________ pressure (as blood leaves the aorta into the arteriole end of capillaries (squeeze) from arteries pushes some fluid out; as blood passing to venules (protein back in)
hydrostatic; oncotic
Third Spacing
Condition where fluid accumulates in a pocket that is not serving a purpose
- can occur anywhere
Ascites
fluid in abdominal cavity peritonitis/pancreatitis
Third spacing occurs as a result of
increased permeability of the capillary membrane
or decreased plasma colloid osmotic pressure. (oncotic pressure)
Main causes of edema
- Long periods of standing or sitting (usually in feet, ankles, and lower legs)
- Venous insufficiency
- Chronic lung diseases
- Congestive heart failure
- Pregnancy
- Low protein, starvation
Edema can occur from
intestinal obstruction
heart failure - no pushing fluid = build up of hydrostatic pressure
peritonitis
liver failure
starvation
Of the 60% of lean body weight (water), what fraction is intracellular, extracellular, and blood plasma?
Intracellular 2/3
Extracellular 1/3
Blood Plasma 5%
Extracellular
interstitial fluid
Edema
an accumulation of interstitial fluid within tissues
Hydrothorax
collection of extravascular fluid in pleural cavity
Hydropericardium
collection of extravascular fluid in pericardial cavity
Hydroperitoneum / Ascites
collection of extravascular fluid in peritoneal cavity
Anasarca
severe, generalized edema marked by profound swelling of SubQ tissue and increase fluid in cavities
What nursing interventions can you do for edema
Daily weight
I&Os
If your patient has significant weight gain, then they are _____________ water.
retaining
If they have gained 2 lbs over night, I&O is good, then what nursing intervention would you do?
Lung and cardiac assessment
VS
The patient has gained 2 lbs overnight and I&O is good. After doing a respiratory and cardiac assessment, the nurse discovers crackles.
-What can the nurse interpret from these findings?
- What should the nurse do?
- Build up of fluid in the lungs
- O2 Therapy, elevate HOB, TCDB (possibly stop fluid if retaining)
Active Transport included what electrolytes?
Sodium and Potassium
Explain Active Transport
sodium and potassium use ATP to move in/out of cells - sodium-potassium pump
Na and K use ATP to move in/out of cells in a form of active transport called
sodium-potassium pump
What energy is used to move electrolytes through the sodium-potassium pump?
ATP
ICF is fluid ________ the cells
inside (intracellular 2/3)
ECF is fluid _________ the cells
outside (Extracellular 1/3)
What are the 3 different types of ECF?
Intravascular
Interstitial
Transcellular
Intravascular
found in the vascular system that consists of arteries, veins, and capillary networks
- whole blood volume includes RBC, WBC, plasma, and platelets.
Interstitial
fluid between cells – “third space”
Transcellular
cerebral spinal fluid, synovial fluid, peritoneal and pleural fluid
– only ALLOWS some things if it serves a purpose
Each of the fluid compartments is separated by a selective _________ __________ that permits mvmt of water and solutes
permeable membrane
What molecules move freely between permeable membranes into other compartments?
small (urea and water)
What molecules do not cross readily between permeable membranes into other compartments?
Larger (protein)
Osmolality is measured in
milliOsmois/ kg
Osmolarity is measured in
milliOsmois/ Liter
Osmolality is used to assess
body’s state of water balance
-urine
What is the only difference between Osmolality and Osmolarity?
Osmolality = kg
Osmolarity = L
High osmolality
water deficit
Low osmolality
water excess
Normal osmolarity
270-300 mOsm/L
Osmole
The concentration of solution measured
Normal serum osmolality
275-295 mOsm/kg
High Osmolarity of urine
concentrated urine (less liquid and more particles)
- dehydrated
Low Osmolarity of urine
diluted urine (more liquid and fewer particles)
Isotonic Fluid Concentration
Shifts?
- equal to match I-so-perfect
- same solute concentration
- No fluid shifts occur bc of equally concentrated
Hypotonic Fluid Concentration
- less concentrated (fewer solutes/more solvents)
- fluid pulled/moved from the bloodstream (veins) into the cells
= SWELL
What is the mnemonic for Hypotonic solutions?
Hippo / Hypo It’s off to the cells we go
Hypertonic Fluid Concentrations
more concentrated than other solutions
- fluid pulled from cell into bloodstream
= shrink
Mnemonic for Hypertonic
hyper = energy; makes cells skinny; fluid escaping from cells
What organs maintains fluid balance?
kidneys and lymphatic system
How does the lymphatic system help maintain fluid balance?
- collecting excess fluid and particulate matter from tissues
- depositing them in the bloodstream
- defend the body against infection by supplying disease-fighting cells (lymphocytes)
What hormones are used to maintain fluid balance?
- ADH (Anti-diuretic hormone)
- RASS (Renin - Angiotensin - Aldosterone System)
- Aldosterone
- ANP (Atrial Natriuretic Peptide)
THIRST
Main Purpose of kidneys
regulate fluid/electrolyte balance by adjusting urine volume and the excretion of electrolytes
- remove excess water
- Na and K filtered or reabsorbed
If loss of 1 -2 % fluid, then kidney …
Leads to …
reabsorbs more water
= concentrated urine
What are the 7 functions of the kidneys?
A - control ACID-base balance
W - control WATER balance
E - maintain ELECTROLYTE balance
T - remove TOXINS and waste
B - control BLOOD PRESSURE
E - produce ERYTHROPOIETIN
D - activate vitamin D
An anti-diuretic hormone is produced by and stored
- produced by hypothalamus
- stored in pituitary
ADH purpose
- restores blood volume
= reduce diuresis
= increase water retention
= vasoconstrictors
ADH is usually made by the body naturally, but what is the medication form of ADH?
Vasopressin (Desmopressin)
- usually IV and critical dosage
- Don’t stop if getting a blood draw
What control the excretion of fluid?
nephrons
Diuretic
removes water
Antidiuretic
retain water
Diuresis
amount of urine
When the body becomes hypotensive or does not have enough water, what does the body do?
Brain will release ADH to kidneys for reabsorbed liquids
- release less water
- constrict the veins
- increase bp
SIADH
Syndrome of Inappropriate ADH
If the body is dehydrate, deficit of water, then ADH ____________ .
Increases
- water is absorbed/conserved for
= concentrated urine
If the body is hydrated (excess water), then ADH is
released and less water is absorbed
= urine diluted
What is the RAAS
- ECF low
- Renin produces angiotensinogen
- Produces angiotensin 1
- Converts to angiotensin 2 = massive vasoconstriction
- A2 stimulates release of aldosterone
- retention of water and sodium
- aldosterone and vasoconstriction = increase of bp
When is RAAS activated?
decrease of Extracellular fluid
Hormone Order for RAAS
Renin
Angiotensinogen
Angiotensin 1
Angiotensin 2
Aldosterone
RAAS ultimate goal
increase volume of fluid (aldosterone) and bp
What does Aldosterone do in the body?
Released if?
- water regulator
- kidneys to retain Na and water
- released if low Na and K high
Where is aldosterone made?
adrenal cortex
- keep Na and release K from the body
Too much aldosterone can cause
high bp
build up of fluid
Atrial Natriuretic Peptide (ANP) purpose
- stops RAAS
- decrease bp by vasodilation
- reduces fluid volume by increasing secretion of Na and water = lowers bp
Role of ANP
cardiac hormone
- lower bp and to control electrolyte homeostasis
When is ANP secreted from the heart?
sodium levels and bp are increased
ANP and BNP are secreted from
cardiac atria and ventricles
BNP acts ________ to reduce ventricular fibrosis
locally
High BNP means
heart can’t pump the way it should
- greater than 100
The higher the BNP, the more likely
heart failure is present and severity
What diet does someone with high blood pressure eat?
low sodium
What is the simplest method of maintaining fluid balance?
Thirst
- result of smallest loss of fluid or high salty foods
= drying of mucous membranes in mouth
- regulated hypothalamus
What depletes electrolytes?
Vomit
Pee
Poop
Sweat
Where fluids flow
electrolytes go
Hypovolemia
fluid volume deficit of isotonic in ECF
Hypovolemia is caused by
Abnormal
- fluid loss
- fever, excess perspiration (sweat)
- hemorrhage
- vomiting, diarrhea
- GI suction (NG tube)
- Decreased fluid intake
Diuretics
Chronic diseases: heart failure, diabetes
Third-space fluid shifts ( burns, liver dysfunctions, trauma )
Clinical Manifestations of Hypovolemia
develop quickly, severity depends on the degree of fluid loss
= Decreased vascular volume
Hypovolemia is/isn’t the same as dehydration.
Is not
What is the difference between hypovolemia and dehydration?
Hypovolemia is water loss and electrolytes concentration is the same
but dehydration is just loss of water causing sodium to rise
With volume loss or excess need to ** monitor** what?
electrolytes
Hypovolemia is common among what age groups
very young and very old
During dehydration, water shifts …
water shifts out of cells and into ECF and cells shrink
Hypervolemia is caused by
abnormal retention of water and sodium in same proportions which they normally exist in ECF
Hypervolemia is fluid volume
excess
Hypervolemia is caused by
Isotonic fluid overload (ECF increase in interstitial/intravascular compartments)
excess sodium intake
heart failure, renal failure, liver cirrhosis
Hypervolemia treatment involves
underlying cause and remove fluid w/o causing changes in electrolytes or osmolality of ECF
Hypertonic solutions move fluid from
from interstitial space to expand extracellular space
- cells shrink
Hypertonic solutions are ordered for what type of pts?
Why?
postoperative pts
- reduce risk of edema, stabilize bp, and regulate urine output
IV Cannulations start where
low and work proximally
- inner wrist is sensitive
- AC is last option!
IV Cannulations and Phlebotomy relies heavily on
feel/touch not sight
IV Cannulations sites to avoid
Legs, ankles, and feet
Sclerosed or thrombosed veins
Veins that are knotted or tortuous
Veins below an infiltrated site or areas of phlebitis
Areas of inflammation, disease, bruising, or breakdown
Veins of surgically compromised or injured extremities
Dominant hands (if possible) and extremities with AV shunts for dialysis
Considerations for selecting a vein
condition of the vein (fragile?)
reason for IV
what solutions or meds used (irritating)
Vein Evaluation what do you do and look for?
PALPATE
- suitable: round, firm, and elastic
engorged with tourniquet
14-16 g needles are used for
trauma or surgery when needing rapid infusion
18 g needle is used for
surgery, receiving blood or caustic meds
In normal everyday IV catheter, what needle gauge would you use?
20 -22 g
24 g
most common in peds
used on adult with fragile veins
What are the different types of IV catheter insertion devices
Nexiva Winged
Insyte Autoguard
Complications of IV Therapy
- a fluid overload of the circulatory system (stress on heart)
- infection (redness, irritation, and pain)
- phlebitis (irritation to vein mechanical:tube itself or chemical: medication)
- infiltration: fluid seeps into tissue like 3rd spacing (swollen, cold
- extravasation: infiltration of caustic meds and eats away tissue
Intermittent (INT)
scheduled dose daily or several times a day
Continuous
IV solutions are constant
-used for hydration, electrolyte replacement
Bolus/Push
specific amount in a specific time frame
Nurse Responsibilities for IV
Assess patency, irritation, and infection (once per shift)
Know the medication
Assess for adverse effects
Teach the patient
IV Medication advantages
Direct access to circulatory system instant action
Instant drug action and drug termination
Rapid treatment
Better control of rate
Great for those with GI tract limitations
Good for meds that irritate gastric mucosa
IV Medication disadvantages/complications
Reconstitution errors: recommeded volume of diluent
Venous Spasm
Drug incompatibilities
Impaired drug absorption
Speed Shock
Chemical phlebitis
Extravasation of vesicants
Air embolism
Venous Spasm
sudden, brief, tightening of the muscle cells inside the blood vessel walls.
Speed shock
from too much medication in too short a period of time
-It could result in systemic reactions depending on the drug.
-Make sure you administer all medications at the recommended rate
Chemical phlebitis
inflammatory damage to the lining of blood vessels with chemical irritation
Air embolism
when air enters the central veins and becomes trapped in the blood
What are the causes of air embolisms?
Solution runs dry, air in tubing, loose connections, improper removal of CVAD, poor technique with dressing or tubing changes
S/S of air embolism
Dyspnea, tachypnea,
lightheadedness,
palpitations,
drop in BP,
weakness,
cyanosis, expiratory wheezes
Air embolism Interventions
Stay witht pt and Call for help
- Position the patient in Trendelenburg on their left side
- Administer oxygen
- Monitor vital signs
- Have emergency equipment ready
S/S of extravasation
Pain or burning at IV site
Skin tightness at site
Blanching and coolness of skin
Dependent edema
Prevention of extravasation
Dilute meds as recommended
Avoid use of high pressure pumps
Assess & monitor IV site
Teach patient what to report
Extravasation
vesicant drugs can result in tissue necrosis or the formation of blisters when infused into the tissue surrounding a vein.
= lead to permanent damage and even death.
Which device is the safest for the administration of vesicant drugs?
CVADs
Causes of venous spasms
Viscous solutions
Too rapid administration
Cold or irritating solutions
S/S of venous spasms
Sharp pain radiating up the arm with the IV site
Prevention Techniques of venous spasms
Dilute meds as recommended
Admin solutions and meds at room temperature
Admin at the recommended rate
Restart questionable IVs
Consider a warm compress during infusion
Causes of chemical phlebitis
Too rapid infusion
Presence of particulate matter in solution
Improper dilution or reconstitution when preparing meds
Administration of irritating meds
Prevention of chemical phlebitis
Use an in-line filter for meds that do not reconstitute completely
Increase the volume of dilution
CVAD or larger peripheral veins for IV site
Slow the rate of infusion
Restart any questionable IVs
IV Push Administration procedure
- 7 rights, Verify Patient and allergy status
- Scan patient’s arm band and med vial and verify with eMAR (3rd check)
- Hand hygiene & don clean gloves
- Remove alcohol permeated cap from IV lumen
- clean needleless connector access with alcohol pad for 15 sec
- Purge air from a sterile saline flush syringe = attach syringe = flush lumen and IV catheter with 9 mL = remove syringe
- Clean needleless connector access = attach medication syringe = administer med at recommended rate = remove syringe
- Clean needless connector access = attach post saline flush syringe
-
flush slowlyfor the first 2-3 mL
then vigorously for total of 9 mL - Remove flush syringe = clamp lumen= attach new alcohol permeated cap
Formula for gtts/minute for gravity infusion
mL*drop factor/mins
What do you do with tubing before attaching primary or secondary tubing?
clamp and Prime
How to prevent venous spasms
warm fluids to room temperature so they’re not cold.
How to prevent air embolisms?
Always ensure you purge air from syringes and prime tubing, and secure all connections properly.
