Unit 11: Fluid, electrolytes, and IV therapy Flashcards
Function of body fluid
- Building of body cells and tissues
- Tx of nutrients, electrolytes
- Carrying waste products from cells
- Regulation of body temp (sweating)
- Lubrication of joints and membranes
- Medium for food breakdown and digestion
2 types of fluid
- Intracellular
- Extracellular
What is extracellular plasma made of?
- Plasma: 3L
- Interstitial: 10 L
- Intracellular: 28 L
Solution
A mixture of solutes dissolved in a solvent
Osmosis
Movement of water through semipermeable membrane.
Osmotic pressure
Pressure needed to stop osmotic flow of water.
Osmolality
Solute concentration by weight of solvent.
Tonicity
Concentration of solutes dissolved into a solution, determines the direction and extent of fluid diffusion.
Crenation
shrink
Electrolyte
Substances whose molecules dissociate or split into ions when placed in solution.
Ions
Electrically charged particles
Cations
Positively charged ions
Anions
Negatively charged ions.
What anions and cations are present within the plasma?
Ca, K, Mg, Cl, HCO3, negatively charged proteins, other, and PO4
What anions and cations are present within the Intracellular?
K, Na, Mg, PO4, negatively charged proteins, HCO3, Cl
K
- Muscle and nerve impulses
- ICK cation
- Maintains cardiac rhythm
- Acid-base balance
- Promotes cellular growth
Na
- ECF cation
- Controls H2O distribution between ECF and ICF
- Generation and transmission of nerve impulses
- Acid-base balance
Ca
- Transmission of nerve impulses
- Myocardial and other muscle contractions
- Blood clotting
- Formation of bones and teeth.
Mg
- Coenzyme in carb and protein metabolism
- Metabolism of nucleic acids
- Helps maintain cardiac function
Cl
- Acid-base balance
- ECF anion
- Water balance
- Part of gastric acid for digestion and activation of enzymes
PO4
- ICF anion
- Muscle, RBC, and nervous system Fx
- Formation of bones and teeth with calcium
- Acid-base balance
- Mitochondrial energy production of ATP
- Cellular uptake and use of glucose
- Metabolism of carbs, proteins, and fats
Subjective data
- PMHx (disorders)
- Meds
- Surgery and/or treatments (dialysis, ostomy, GI Sx)
- Diet (Fad diets and prescribed diets)
- Elimination patterns (Nocturia, polyuria, and diarrhea)
- Exercise patterns (Replenishing electrolytes)
- Changes in sensation, muscle weakness, mentation, or alertness.
Objective data: Physical examination
- VS
- Integumentary system
- Respiratory system
- MSK
- Behaviour and mental state
Objective data: Lab values
- Serum electrolytes, renal panel
- U/A
- ABG
Correcting imbalances: Oral fluid and electrolyte replacement
- Mild imbalances
- Solutions containing H2O, electrolytes, and glucose
Correcting imbalances: IV fluids
- Peripheral IV
- Central venous access device (CVAD): thread into superior vena cava
What are IV fluids used for?
- Correct fluid and electrolyte balance
- Administer meds
- Diagnostic tests or anesthesia
- Correct or maintain code status
Types of IV fluids: Isotonic solutions
- Fluid replacement
- Can cause fluid overload in patient with renal or cardiac disease
Types of IV fluids: Hypotonic solutions
- Causes movement of H2O from ECF to ICF
- Can cause hemolysis of RBCs and cerebral edema
- Used for fluid maintenance
Types of IV fluids: Hypertonic solutions
- H2O from ICF into ECF
- Increase risk for heart failure and intracellular dehydration
- Used to treat hypovolemia and decrease Na
Names, tonicity and functions of IV fluids
- D(dextrose)5W Isotonic: Supplies H2O, treats increased Na, 170 cal/L
- D(dextrose)10W Hypertonic: Supplies H2O, 340 cal/L
- 0.9 % NaCl Isotonic (nm saline): Expands intravascular fluid volume, replaces ECF losses.
- 0.45 % NaCl hypotonic (1/2 nm saline): Replaces fluid volume for pt with increased Na.
- 3-5 % NaCl (3-5 %nm saline) hypertonic: Treats symptomatic decrease in Na.
- Ringer’s (lactated) Isotonic: Expand intravascular fluid volume, replaces ECF losses.
Complications of IV therapy: Infiltration
- Fluid leaks into interstitial space
- S & S:
+ Coldness
+ Pain
+ Pallor
+ Swelling around
infusion site
Actions to correct complications of IV therapy
- Assess IV site q/h
- Stop infusion and restart at a different site
- Limit movement of extremity with IV.
Stages of one IV infiltration
Painful IV site, no erythema, no swelling
Stages of two IV infiltration
Pain, slight swelling, no blanching of finger, good pulse and brisk cap refill
Stages of three IV infiltration
Pain, marked swelling, blanching, skin cool to touch, good pulse, and brisk cap refill
Stages of four IV infiltration
Pain, very noticeable swelling, blanching, skin cool to touch, decrease or absent of pulse, cap refill more than 4 seconds, skin breakdown or necrosis
Complications of IV therapy: Extravasation (what is it? S & S, and action)
What is it?
- Infiltration of chemotherapy or other harmful drug into tissues around IV site.
S & S:
- Pain
- Edema
- Blistering
- Tissue destruction
- Infection
- Loss of function in extremity
Nursing Action:
- Stop infusion
- Treat symptoms and alert physician of any changes
Complications of IV therapy: Phlebitis (what is it? S & S, and action)
What is it?
- Irritation and inflammation of vein
- Formation of clots = thrombophlebitis
S & S:
- Discomfort
- Edema
- Erythema
- Warmth
Nursing Action:
- Stop infusion
- Apply warm, moist compress
- Start IV in another site
Complications of IV therapy: Infection (what is it? S & S, and action)
What is it?
- Introduction of microorganisms
S & S:
- Pain
- Edema
- Erythema
- Warmth
- Fever
Nursing Action:
- Surgical asepsis when inserting and caring for IVs
- Assess q1h
Complications of IV therapy: Fluid overload (what is it? S & S, and action)
What is it?
- Rapid administration of IV fluids
- Those who are most vulnerable include: babies, elderly, cardiac or renal disease.
S & S:
- Increase BP
- Resp. distress
- Crackles over lung fields
- Edema
- Weight gain
Nursing Action:
- Stop infusion rate
- Monitor VS
- Notify physician
Electrolyte imbalance assessments
- Review physician’s orders
- Check order for solution, volume, flow rate, duration of therapy
- Asses lab values, allergies, other health conditions, behaviour, LOC, pt knowledge.
- Skin turgor, dependent edema, oral mucosa
- Assess IV insertion site
Process to hook up an IV
- Gather supplies
- Prime and label line
- Flush saline lock
- Regulate flow rate
- Regulate flow rate by gravity
gtts/min = (mL/hr x drop factor)/(time in mins) - Regulate flow rate by pump
Removing IV
- Check physician’s orders
- Assess IV site and note whether pt is on any anticoagulants
- Remove tape and dressing
- Stabilize catheter
- Remove catheter, ensuring there’s a tip.
- Place gauze over site
- Apply bandage and gauze with tape
