Week 4 Nursing

Question 1

Body Fluid Compartments

Answer 1

▪ The body has three major fluid compartments:
– Intracellular space
– Interstitial space
– Intravascular space
▪ Separating compartments are two semi-permeable barriers
– Capillary wall
– Cell membrane

Question 2

Regulation of Body Fluid Compartments

Answer 2

▪ Movement between compartments occurs via these regulatory mechanisms:
– Movement of fluids
▪ Osmosis
▪ Filtration (Hydrostatic & Oncotic pressures)
– Movement of electrolytes
▪ Diffusion
▪ Active Transport
▪ These mechanisms maintain the balance between:-
– Intracellular fluid (ICF) and Extracellular fluid (ECF)
– Interstitial and intravascular spaces

Question 3

Colloid Osmotic Pressure – Oncotic Pressure

Answer 3

• The capillary membrane is readily permeable to ions. This means that the osmotic pressure in blood vessels is determined principally by the plasma proteins (i.e albumin).
• This osmotic “pull” of these blood proteins is called oncotic pressure.
• Oncotic pressure keeps fluid within the intravascular space.

Question 4

Hydrostatic pressure

Answer 4

▪ Hydrostatic pressure is the force exerted on the blood vessel wall by a fluid. ▪ As the volume of blood ↑, hydrostatic pressure ↑
▪ The balance between oncotic and hydrostatic pressures determines fluid movement between the intravascular and interstitial spaces

Question 5

Indications for Intravenous Fluid

Answer 5

▪ Replacement of extracellular fluid loss
– Haemorrhage
– Non-haemorrhage fluid loss
▪ Maintain fluid and electrolyte balance
– Nil by mouth
▪ Correct existing electrolyte or acid-base abnormality
- Hypernatremia / Hyponatraemia
– Acidosis / Alkalosis
▪ Provide a source of glucose
– Hypoglycaemia

Question 6

Types of Intravenous Fluid

Answer 6

▪ Two main types
1. Colloids
2. Crystalloids
- Isotonic
- Normal Saline
- Balanced Solutions
- Hypertonic
- Hypotonic

Question 7

Colloids

Answer 7

▪ AKA volume or plasma expanders
▪ Molecules are too large to pass through the semipermeable membranes so they expand intravascular volume but exerting colloid osmotic pressure and “pulling” fluid in.
▪ The molecules remain in the intravascular space longer, which leads to longer duration of action than crystalloids and less volume required.

Examples:
* Blood and plasma (the ideal colloid)
* Gelofusin
* Albumen

Question 8

Crystalloids

Answer 8

▪ Crystalloid solutions contain water soluble electrolytes including sodium and chloride. They lack proteins and insoluble molecules.
▪ Distribute throughout ECF
▪ Classified according to tonicity
1. Isotonic – same concentration of electrolytes as plasma
2. Hypertonic – greater conc. of electrolytes than plasma
3. Hypotonic – lower conc. of electrolytes than plasma

Question 9

Isotonic solutions

Answer 9

▪ Solutions that have the same tonicity as blood are considered isotonic
▪ Isotonic solutions distribute throughout the ECF
▪ Patient use:
– Hypovolaemic shock (bolus dose)
– Isotonic dehydration
▪ Examples:
– 0.9% NaCl (Normal saline)
– Hartmann’s solution (AKA Ringer’s lactate)
– Plasmalyte

Question 10

Hypertonic solutions

Answer 10

▪ Hypertonic solutions have a greater tonicity than blood
▪ Draws water out of the cell and into the extracellular space
▪ Patient use:
– Hyponatremia
– Cerebral oedema
▪ Examples:-
– 3% NaCl
– 5% dextrose in 0.9% NaCl (normal saline)*
– 10% dextrose in water (D10W)*

• Dextrose rapidly taken up by cells shortly after infusion, thus decreasing tonicity (D10W becomes hypotonic)

Question 11

Hypotonic solutions

Answer 11

▪ Hypotonic solutions have a tonicity less than blood plasma
▪ Fluids moves out of intravascular/interstitial space and into intracellular fluid.
▪ Patient use:
– Hypernatremia
– No longer recommended for routine maintenance due to risk of hyponatraemia
– Contraindicated in head injuries
▪ Examples:
– 0.45% NaCl (1/2 normal saline)

Question 12

Vascular Access Devices

Answer 12

▪ Vascular Access Devices (VADs)
1. Peripheral Venous Cannulas
2. Central Venous Catheters
a. Central Venous Catheters
b. Peripherally Inserted Central Catheters (PICC)
c. Implanted Ports

Question 13

Peripheral Venous Cannulas

Answer 13

▪ Clear plastic catheter sits over the hollow introducer needle.
▪ Venipuncture is performed and blood is seen in flashback chamber when vein is accessed.
▪ Catheter is then advanced off the introducer and into the vein.

Question 14

Choosing an IV site

Answer 14

▪ Arm veins usually used.
▪ Potential IV sites are assessed for suitability:-
– Consider dominant hand (leave free)
– Away from flexion (wrist or antecubital fossa)
– Surgery side (left shoulder surgery
– site on right side)
– Injury (mastectomy, neuro deficit)
– Localised injury (oedema, cellulitis, skin grafts)
▪ Distal sites are preferred initially
– Allows for more proximal sites if access difficult

▪ Vein inspection
– Firm, elastic, engorged, round.
▪ Not hard, flat or bumpy
– Palpate to ensure no pulse
▪ Arteries sit close to veins
▪ Leg veins
– Only used if arm veins inaccessible.
– Mostly require a doctor to insert these.
▪ Scalp veins
– Use for infants due to ease of accessibility and reduced risk of dislocating needle.

Question 15

Needless Intravenous Delivery Systems

Answer 15

▪ Many IVCs have an inbuilt safety device to reduce the risk of needlestick injury.
▪ The safety shield automatically engages as the tip of the needle passes through the hub of the catheter.

Question 16

Central Venous Catheters – insertion and placement

Answer 16

▪ Inserted via the subclavian or internal jugular vein.
▪ Passed into superior vena cava using guidewire.
▪ Tip sits just above right atrium.
▪ Often have 3 lumens.
▪ Radio-opaque – confirmation X-ray must be performed before use.

Question 17

Central Venous Catheters

Answer 17

▪ Used in acute and high dependency care.
▪ Central Venous Catheters (CVCs) allow:-
– Access for IV fluids, blood products, parenteral nutrition, medication
– Haemodynamic monitoring
– Blood sampling
▪ Different lumens allow for simultaneous infusions and monitoring.
▪ Patient considerations regarding CVCs
– Difficult venous access
– Irritating medications
– Haemodynamic monitoring
– Long term infusions

Question 18

PICCs – insertion and placement

Answer 18

▪ Inserted into basillic or cephalic veins – (above antecubital fossa)
▪ Advanced over guidewire so tip reaches superior vena cava.
▪ Single or double lumen
▪ Radio-opaque – confirmation xray must be performed before use.

Question 19

PICCs

Answer 19

▪ PICCs can remain longer than standard CVCs, as long as needed – up to 12 months.
▪ Patient considerations for PICCs
– Extended periods of medication administration
– Parenteral nutrition
– Chemotherapy (or other specific medications)
– Blood components
– Blood sampling
▪ Prevents repeated venepuncture – reduced infections.

Question 20

Implanted Ports – insertion and placement

Answer 20

▪ Catheter tip in subclavian or jugular vein.
▪ Port placed in subcutaneous pocket in upper chest wall.
▪ No external parts of system are visible.
▪ Special needle used to access.

Question 21

Implanted Ports

Answer 21

▪ A special needle is inserted through the skin and the rubber septum into the reservoir of the port.
▪ Disadvantage is use of needles to access every time.
▪ Used for long term intermittent therapy
– E.g. chemotherapy

Question 22

Care of a CVCs (inc PICCs and Ports)

Answer 22

▪ Use 10ml syringe when flushing Smaller syringes should NEVER be used
– Larger syringes may not provide adequate pressure to clear micro sediment
– Flush using a pulsatile action 🡪 turbulent effect in IVC
– Flush before and after use
– medication/blood admin, blood sampling, when not in use to maintain patency
▪ Prevent blood sitting in catheter/line
– Could clot and stop function of device, may cause pulmonary embolism.
– Use positive pressure bungs, clamping, heparin lock
▪ Aseptic technique when changing dressings
▪ Clean technique when accessing bung (“scrub the hub”)

Question 23

Complications of VADs

Answer 23

▪ IVCs
– Thrombosis, Air embolism, infection, bleeding, occulsion
▪ CVCs
– Pneumothorax, arrhythmias, catheter embolism, nerve/tendon damage.
▪ PICCs
– Infection, cellulitis, infiltration, sepsis

ALL CVCs must be confirmed by X-ray before use.

Question 24

Equipment required to administer IV Fluids

Answer 24

▪ Fluid order
▪ Prescribed fluid
▪ Cannula
▪ Giving Set
▪ Cleanser/disinfectant
▪ Gloves
▪ Tape
▪ Dressing
▪ Armboard
▪ IV stand
▪ Injection tray
▪ Sharps Container
▪ Watch with second hand

Question 25

Equipment – Fluid Order Chart

Answer 25

▪ Written order to indicate the type of fluid and the rate it should be infused (in 24 hours).
▪ As for any medication order it MUST include:
– Patient Identifiers, prescriber signature

Question 26

Equipment - Fluid

Answer 26

▪ Correct fluid is determined by the fluid order chart (8 rights apply)
▪ Safety and Quality checks of the fluid bag:-
– Expiry date
– Type and strength of fluid
– Colour and clarity of IV fluid
– Check bag for leaks by gentle squeeze (condensation from outer bag is ok).
– Time label with time and initials may be attached (but must not obscure the details on the bag.

Two nurses check fluid against fluid order and patient.

Question 27

Equipment - Cannula

Answer 27

• Different gauges
• attempt to use the smallest that can deliver the volume
• Size 14 and 16
• large bore, used in high risk surgery
• requires a large vein.
  · Size 18
• used in trauma, blood transfusions, CT with contrast
  · Size 20
• most commonly used. Ok for fluids and blood.
  · Size 22 and 24
• used for smaller veins. In elderly or paediatric patients.

Question 28

Equipment – Giving set

Answer 28

▪ Giving sets are the tubes that deliver the fluid – they have an inline drip chamber.
1. Gravity sets
2. Infusion pump sets
▪ Blood/inotropes
▪ Macrodrip giving rates
– Chamber 20 drops per ml
▪ Adults
– Chamber 60 drops per ml
▪ Paediatrics/elderly

Question 29

Monitoring the flow rate – equipment and devices

Answer 29

▪ Burette
– A measured tube that goes ‘in-line’ between the giving set and the IV fluid.
– The IV fluid is clamped at the top, so only fluid in the burette can be infused at one time.

▪ Infusion pumps
– They regulate the rate of fluid to be infused in mls/hr.
– Use specific giving sets that fit the infusion pump.
– Pump alarms if air in line, if fluid has completed or if IV is blocked

▪ Syringe drivers
– Deliver small volumes of fluid
– 60 mls.
– Used for paediatrics, or certain medications.

Question 30

Other equipment

Answer 30

▪ Cleanser/disinfectant
– Alchowipes, chlorhexidine, betadine (depending on facility policy)

▪ Gloves
– Standard precautions

▪ Tourniquet
– Reduce back flow of blood, distend veins to ease cannulation.

▪ Tape and Dressing
– To anchor cannula. Depends on policy, but transparent dressing common

▪ Armboard
– Only if required to stabilise joint to ease flow.

▪ Watch with second hand
– Needed to time the infusion rate.

Question 31

Complications associated with IV fluid administration

Answer 31

▪ Complication associated with IV fluid administration can be divided into two:
1. Systemic complications
▪ Occur less frequently, but often more serious
2. Local complications
▪ Occur at or near the IV insertion site

Question 32

Systemic IV complications – Fluid Overload

Answer 32

▪ Fluid Overload
– Too much IVF leads to hypervoleamia and increased CVP
▪ Signs & Symptoms
– Fine crackles, oedema, cough, restlessness, weight gain, dyspnoea, increased shallow RR, distended jugular veins.
▪ Cause
– Rapid infusion of IVF, renal, or cardiac disease.
– Can lead to acute pulmonary oedema (APO) – esp in elderly – circulatory overload

Question 33

Systemic IV complications – Fluid Overload – Patients at risk

Answer 33

Patients at risk of Fluid Overload
▪ Paediatric patients
▪ Elderly patients
▪ Cardiac disease
– When heart is not pumping effectively, fluid backs up into lungs.
▪ Renal disease
– Kidneys are not functioning properly, cannot eliminate fluids at rate to match the infusion

Nursing Management (as always, start with DRSABC)
* Stop infusion, sit up (Fowlers), MET call if abnormal vital signs
* Focused cardiac and resp assessment. Provide reassurance.
* Apply oxygen and titrate to SpO2. Notify MO.

Question 34

Systemic IV complications – Air Embolism

Answer 34

▪ Air Embolism
– Air enters vascular system and displaces blood. Rare.
▪ Signs and Symptoms
– Dyspnoea, cyanosis, hypotension, weak pulse, increased HR, LOC, chest/shoulder/low back pain.
▪ Cause
– The rate of entry of air as well as the volume of air. Most likely in cannulation of central veins.
▪ Treatment
– Clamp cannula, assess vitals, place on left side, head down position.

Question 35

Systemic IV complications – Infection

Answer 35

▪ Infection
– Through IV solution or administration set.
▪ Signs and Symptoms
– Sudden temperature rise, tachycardia, hypotension, tachypnoea, decreased urine output (signs of sepsis).
▪ Cause
– Poor ANTT, contamination of IV fluids/medication. These increase if pt immunocompromised.
– Sepsis has 10-20% mortality rate
– Regarded as totally preventable
▪ Treatment
– Symptomatic treatment. Cultures of IV tubing/solution.

Question 36

Local IV Complications – Infiltration

Answer 36

▪ Inadvertent administration of solution/medication into surrounding tissue. ▪ Oedema, swelling, inflammation ▪ Can occur when IV cannula dislodged from vein.
▪ Treatment
– Stop infusion
– Remove IVC
– Cold compress

Question 37

Local IV Complications - Phlebitis

Answer 37

▪ Inflammation of vein due to chemical or mechanical irritation.
▪ Warm IV site or along vein, pain, swelling.
▪ Treatment
– Stop IV
– Warm compress to site
▪ Prevention
– Good ANTT
– Appropriate size cannula for vein

Question 38

Local IV Complications - Extravasation

Answer 38

▪ Inadvertent administration of irritant into surrounding tissue
▪ Blistering, inflammation, necrosis
▪ Treatment
– Stop infusion
– Notify Doctor
– Follow extravasation protocol
– Antidote may be given
– Neurovascular observations

Question 39

Local IV Complications - Haematoma

Answer 39

▪ Blood leaks into surrounding tissue.
▪ Due to needle slipping out of vein, or poor pressure when cannula removed.
▪ Bruise
▪ Treatment
– Remove IVC
– Pressure

Question 40

Local IV Complications – Clotting and obstruction

Answer 40

▪ Blood clots from in IV tubing due to
– Kinked IV tubing
– Kink/bend in IVC
– Slow infusion rate
– not flushed regularly
– Empty/neglected IV bag
▪ Indicated by stopped or reduced flow
▪ If clot in IV line
– Stop infusion and start again with new set and line
▪ If clot in IVC
– KVO (keep vein open)
– maintenance fluids/regular flushes
– Doctor may inject a thrombolytic agent

Question 41

Local IV Complications - Thrombophlebitis

Answer 41

▪ Clot and inflammation in the vein.
▪ Pain, redness, warmth, swelling. Immobility of extremity, fever.
▪ Treatment
– Stop IV
– Apply cold compress (reduces flow) then warm compress and elevation.
– Do not flush line - clots

Question 42

Infection prevention measures

Answer 42

▪ Hand hygiene before contact with set, fluids, patient.
▪ Check IV containers for cracks/leaks, fluid for cloudiness
▪ Good anchoring of IV to prevent movement (stay in vein)
▪ Daily inspection of IV site.
▪ 8/24 checking of patency – N/S Flush
▪ “Scrub the hub” before accessing bung
▪ Change IVC as per facility policy – often 72 hours
– IVCs inserted in emergency/pre-hospital situations sooner.
▪ Replace fluid and giving set as per policy.
▪ IVC insertion sites should be rotated at least every 72-96 hours (depending on health service policy)

Question 43

Monitoring the patient receiving IV fluids

Answer 43

▪ Doctors prescribe the fluid and the rate that it should be given.
– The rate is described as the number of hours it should run for – e.g. 4/24, 8/24,12/24 etc
▪ Nurses maintain the flow rate*.
– Determined by the amount of solution to be infused over an hour – drip rate.
– Drip rate is determined by the size of the lumen of the giving set.
▪ Various sizes, the most common being 20 or 60 drops per ml
– Important to ensure fluid is at appropriate rate and will not affect the fluid balance.

*Flow rate calculations will be covered in your workshop/lab this week.

Question 44

Fluid and giving set changes

Answer 44

▪ Giving set changes
– Most facility policies state change every 72 hours
– Giving sets used for TPN, blood and some medications will require more frequency – 24hrs
▪ Fluid changes
– Occur at the end of an infusion – keep sterility of IV system
▪ Piggy-back infusions
– Whilst IV infusion taking place, another IV solution or medication can be added onto the existing fluid via the port.

Question 45

IV administration - Blood

Answer 45

▪ Indications for giving blood
– Volume loss (trauma, surgery, haemorrhage), clotting abnormalities, anaemia
▪ Blood cross matching
– Patient must be cross matched to identify their blood group.
– Patients receive their own blood group – except in emergencies where type O- can be used.
– If patient is given the wrong blood – they may have a haemolytic reaction.
▪ Blood products
– There are different blood products including – whole blood, packed red cells, plasma, platelets, serum albumen, cryopreciptate.

Question 46

Monitoring the flow rate

Answer 46

▪ Factors which may affect the flow rate include:-
– The height of the fluid in relation to the person
– The person’s position (inc limb position)
– The patency of the IV system – line and cannula
▪ Blocks, knots, kinks, clamps
– Blood pressure
▪ IV infusions should be checked hourly
– Patient movement, medication administration, equipment changes can all affect the IV rate.

Question 47

IV administration - Blood Monitoring

Answer 47

▪ Due to the risk of haemolytic (transfusion) reaction, patients receiving blood require close monitoring.
▪ Blood checking procedure
– Blood must be given within 15 minutes of arrival on ward –
2 RNs must check patient (ID, blood type), blood pack (expiry date, unit ID number), prescription (fluid order, infusion rate, number of units).
▪ Blood administration
– Baseline set of vital signs
– Start infusion slowly – reactions occur in first 10-15 mins
▪ Blood monitoring
– Vital signs every 15 mins in first hour, then every 30 minutes.
– If changes in vital signs occur – stop infusion, advise NIC/MO

Facility policy may vary – check locally

Question 48

IV Administration – Potassium

Answer 48

IV potassium must NEVER be given as a bolus (or push) - may cause potentially fatal cardiac arrhythmias.

• Potassium should not be given at a rate faster than 10 mmol/L per hour * Separate ampules of potassium should not be used and should not be added to IV bags.
• IV fluids with potassium have red writing on them as a warning.