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LPN-CLPN-C
Unit Four
Rationale for Intravenous Therapy
What is the Purpose ofWhat is the Purpose ofIntravenous Therapy?Intravenous Therapy?
Maintenance◦Water◦Glucose◦Protein◦Vitamins◦Electrolytes◦pH
Restoration of previous lossesReplacement of present lossesAdministration of medication
WaterWaterWater is necessary for adequate kidney function –
Normal Intake Normal OutputOral liquids 1300mLUrine
1500mLWater in food 1000mL Stool
200mLMetabolism 300mL Lungs
300mLTotal 2600mL Skin
600mLTotal 2600mL
Individual fluid requirements vary◦Total body water percentage is higher in infants
(80% compared to 60% in adults)◦ Infants require more water than older children or
adults◦ Infants are more vulnerable to fluid volume deficit
GlucoseGlucoseConverted to glycogen by the liverHas 4 main uses in parenteral
therapy◦Improves hepatic function◦Supplies the necessary calories for energy
◦Spares body protein◦Minimizes ketosis
Approximately 100 – 150g of glucose is needed daily to minimize protein catabolism
1 liter of 5% dextrose in water supplies 50g of glucose
Dextrose in water is available in 2.5%, 5%, 10%, 20%, and 30%
Glucose (cont’d)Glucose (cont’d)Dextrose concentrations higher than 10% must be given through a central vein◦The exception is 50% dextrose slow IV push at a rate of 3mL/min through a peripheral vein for emergency treatment of hypoglycemia
ProteinProteinAmino acids are the building blocks of the body◦Tissue growth and repair◦Wound healing
Available in concentrations of 3.5 – 15%
Used in TPN centrally and peripherally
Protein (cont’d)Protein (cont’d)Daily requirements = 1g protein/kg body weight◦Amount increases as stress to the body increases
Gluconeogenesis = conversion of protein to glucose to meet energy requirements◦Occurs during starvation, stress, or infection
◦Uses large amount of energy◦Body will use protein for energy if there are inadequate glucose stores
VitaminsVitaminsVitamins B and C are most frequently used◦Vitamin B is needed for the metabolism of carbohydrates and maintenance of GI function
◦Vitamin C promotes wound healing
ElectrolytesElectrolytesCorrection of electrolyte imbalances is important in preventing serious complications
Important in parenteral therapy◦Potassium, sodium, chloride, magnesium, phosphorus, calcium, bicarbonate
Electrolytes (cont’d)Electrolytes (cont’d)Potassium◦Adequate replacement therapy = 20mEq/L◦Patients who need potassium replacement – Stress from tissue injury Wound infection Gastric or bowel surgery Prolonged gastric suction
◦Assess renal function prior to potassium replacement Excreted through the urine Intoxication can occur rapidly and with no
symptoms◦Slow rate of infusion
no more than 20mEq/L per hour via peripheral line
no more than 40mEq/L per hour via central line◦Never give potassium via IV push◦Always use a cardiac monitor with K+ infusion
Electrolytes (cont’d)Electrolytes (cont’d)Potassium (cont’d) --◦Infiltration of potassium is extremely irritating to the tissue Can cause necrosis Imperative to use extravasation
protocol In the case of infiltration, discontinue
the infusion, apply cool compresses, and elevate the extremity by 4 inches
pHpHMost IV solutions are acidic◦Allows for longer shelf life◦The more acidic a solution, the more irritating to the vein
Parenteral NutritionParenteral NutritionPeripheral venous delivery of parenteral nutrition (PPN)◦Glucose concentration is not to exceed 10%
◦Usually utilized for 3 – 7 days◦Assess for metabolic abnormalities
Hyperglycemia Most common metabolic abnormality in PPN Rapid administration of fluid Increased levels of stress hormones
Hypoglycemia can occur if infusion is discontinued abruptly
Hypokalemia Insulin-related shift of potassium from the extracellular compartment to the intracellular compartment
Fluid Balance in Infants and Fluid Balance in Infants and ChildrenChildrenMore vulnerable to fluid volume deficit
Kidneys are immature up to 2 years of age◦Cannot conserve or excrete water or sodium in response to imbalances as efficiently as adults
Body surface area in infants is larger than in adults per size◦Lose more fluid through the skin
Infants have a higher metabolism rate which requires more water per size◦Produce more heat than adults◦Larger amount of metabolic waste to secrete
Less stable regulatory responses to fluid imbalances
Fluid Balance/Infants/Children Fluid Balance/Infants/Children (cont’d)(cont’d)Fevers are higher and last
longer in acute illness◦Increases fluid loss
Symptoms of fluid imbalance◦Decreased appetite◦Less active◦More irritable◦Flaccid appearance◦Diarrhea, vomiting◦Decrease in voiding
Nursing assessment◦Assess concentration of urine
Fluid Balance/Infants/Children Fluid Balance/Infants/Children (cont’d)(cont’d)Nursing assessment (cont’d) --
◦Weigh diapers◦Monitor for diarrhea
Common cause of isotonic dehydration Proportionate loss of water and electrolytes
Formula containing an inappropriately high amount of solute can cause diarrhea that leads to hypertonic dehydration Greater loss of water than electrolytes
◦Monitor for weight changes Record weight before onset of illness
Physician’s records Parent/family/caregiver report
Weight loss resulting from fluid volume deficit is more rapid than with loss of body mass
Fluid Balance/Infants/Children Fluid Balance/Infants/Children (cont’d)(cont’d)Nursing assessment (cont’d) –
◦Monitor vital signs Blood pressure is not always reliable
because elasticity of the blood vessels in children keeps blood pressure stable initially
Tissue turgor◦Skin remains slightly raised for a few seconds with fluid volume deficit
◦Skin turgor begins to decrease after 3-5% body weight is lost as fluid
◦Obese infants/children have deceptive skin turgor Normal in appearance in spite of fluid
volume deficit
Fluid Balance in the ElderlyFluid Balance in the ElderlyAt risk for fluid volume deficit due to normal aging changes◦6% reduction of total body water◦Decrease in ratio of intracellular fluid to ECF
◦Loss of 30-50% glomeruli by the age of 70 Decrease in glomerular filtration rate Decreased ability to concentrate urine Decreased secretion of aldosterone Decrease in the response of the distal tubule
to ADH◦Decrease in glucose tolerance◦Decreased sensation of thirst◦Decreased skin elasticity
Poor indication of turgor◦Atrophy of the sweat glands
Fluid Balance in the Elderly Fluid Balance in the Elderly (cont’d)(cont’d)Normal aging changes (cont’d) --
◦Diminished capillary bed Less effective cooling of body temperature
◦Decreased cardiac output Increased risk for orthostatic hypotension Increased risk for falls
◦Decreased elasticity of arteries◦Immediately assess fluid status with any changes in mental status
Typical assessment findings◦Dehydration frequently seen◦Normal body temperature lower (97°F)◦Mucus membranes less moist◦Positional changes in blood pressure common
Fluid Balance in the Elderly Fluid Balance in the Elderly (cont’d)(cont’d)Typical assessment findings
(cont’d) –◦Most accurate assessment of skin turgor is over the sternum
Special problems in the elderly◦Hypernatremia
Common problem in LTC facilities Immobility Unable to express thirst
◦Reduced motility of GI tract Laxative dependency
◦Heat stroke Elderly more susceptible Decreased efficacy of sweat glands Normal temperature decreases with age
Temperature of 99°F would be high for the body
Fluid Balance in the Elderly Fluid Balance in the Elderly (cont’d)(cont’d)Special problems (cont’d) --
◦Radiocontrast agents (IVP) High in sodium Difficulty excreting due to ↓ glomerular
filtration rate◦Preoperative concerns
Administration of adequate IV fluids before surgery Improves renal blood flow and renal function
Minimum urine output should be 50mL/hour High risk for hypothermia in the operating room
Cool fluids, cool environment, etc.
◦Diminished respiratory function interferes with elimination of carbon dioxide Leads to respiratory acidosis Achieve maximum ventilation through suction,
turning, activity
Fluid Balance in the Elderly Fluid Balance in the Elderly (cont’d)(cont’d)Special problems (cont’d) --
◦Preparation for diagnostic tests Bowel cleansing NPO status
Diet and Lifestyle Factors Diet and Lifestyle Factors Affecting Fluid BalanceAffecting Fluid Balance
Difficulty chewing or swallowing◦Inadequate food/fluid intake
Malnutrition/starvation◦Low protein intake; altered fluid volume status
Excessive alcohol consumption◦Liver damage leading to fluid/electrolyte imbalance
Environmental Factors & Environmental Factors & Fluid BalanceFluid BalanceVigorous exercise increases
metabolism, ventilation, sweating◦Increases fluid demand◦Potential lack of fluid intake
Heat injuries◦Exposure to hot, humid environments increases sweat production to as much as 2L/hour
◦Body fluid weight loss >7% is associated with failure of body cooling mechanisms
Medications Altering Fluid BalanceMedications Altering Fluid BalanceDiuretics = excessive fluid lossChemotherapy = nausea/vomiting,
poor oral intake
Fluid Needs for Those with Fluid Needs for Those with Acute IllnessAcute IllnessSurgery can result in blood and fluid
lossGastroenteritis causes nausea/vomiting and diarrhea
Nasogastric suctioning leads to fluid and electrolyte losses
Brain injury from stroke, trauma, or tumor◦Causes cerebral edema, which may put pressure on the hypothalamus and/or pituitary
◦Alters ADH SIADH Diabetes insipidus Excessive or inadequate ADH production/release
Burns
BurnsBurnsFactors affecting fluid loss --◦Surface area
The larger the burn, the greater the fluid loss
◦Extent, depth, and cause of the burn◦Age of the client◦Pre-existing medical conditions
Diagnostic findings –◦WBC reflects immune function◦Hgb/HCT increases due to fluid loss◦Glucose increases due to stress response
◦Sodium decreases (trapped in third spaces)
◦Potassium increases due to tissue destruction
Burns (cont’d)Burns (cont’d)Third space fluid shifts --◦Phase I → plasma to interstitial space
Occurs rapidly (before the end of the 1st hour)
Plasma leaks out through damaged capillaries at the burn area Edema forms Hypovolemia occurs (may lead to acute tubular necrosis)
Decreased renal perfusion Low urine output Hyperkalemia
Fluid accumulation phase occurs during the first 36 to 48 hours Capillaries have recovered by the end of this time
Burns (cont’d)Burns (cont’d)Third space fluid shifts (cont’d) --◦Phase II → fluid remobilization
Begins approximately 48 hours after burn occurs
Edema at burn site resolving Hypervolemia due to fluid shifting back
into the intravascular compartment Metabolic acidosis due to accumulation
of acids released from the injured tissue Respiratory acidosis due to inhalation
injury that interferes with gas exchange
Nursing assessment –◦Rule of Nines◦Lund-Browder Chart
LUND-BROWDER CHARTRelative Percentage of Body Surface Area Affected by Growth
Age in years 0 1 5 10 15 Adult A-head (back or front) 9½ 8½ 6½ 5½ 4½ 3½ B-1 thigh (back or front) 2¾ 3¼ 4 4¼ 4½ 4¾ C-1 leg (back or front) 2½ 2½ 2¾ 3 3¼ 3½
Burns (cont’d)Burns (cont’d)Treatment --◦Aggressive fluid replacement is necessary to prevent complications Need to induce urine output at 1cc/kg/hour
◦Use large bore IV in a peripheral vein in an area that is unaffected by burn injury 2nd choice = central line in an unaffected area 3rd choice = peripheral line in an affected area Last choice = central line in an affected area
◦Monitor for IV-related sepsis◦Foley catheter placement◦Early burn wound excision◦Timely initiation of enteral nutrition
Fluid Needs for Those with Fluid Needs for Those with Chronic IllnessChronic Illness
Liver disease decreases production of albumin, which affects the ability to maintain vascular volume
Renal disease limits the ability to regulate fluid or electrolytes via urine output
Diabetes increases the risk for hyperglycemia and hypertonic dehydration
Cancer treatment (chemotherapy) induces nausea/vomiting with fluid loss and decreased intake
Diabetic Ketoacidosis Diabetic Ketoacidosis (DKA)(DKA)Occurs in 2 – 5% of people with Type
I Diabetes MellitusMost often begins with an infectionCan also be seen in Type II Diabetes Mellitus if illness or stress exceeds the ability of the pancreas to secrete adequate insulin
Death occurs in 1 – 10% of cases even with appropriate treatment
Onset is sudden (less than 24 hours)Diagnostic criteria includes hyperglycemia, hyperketonemia, and metabolic acidosis
DKA (cont’d)DKA (cont’d)Pathophysiology --Body is unable to utilize carbohydrates◦Not enough insulin to transport glucose into the cells
◦Body resorts to utilizing fats for energyResults in ketones in the blood and urine◦Leads to acidosis
Etiology –Inadequate medication/insulinInfectionChange in diet, exerciseOther stressors
DKA (cont’d)DKA (cont’d)Clinical manifestations --Rapid, weak pulseKussmaul’s respirations“Fruity” breathNausea/vomiting, abdominal painDehydrationPolyuria, polydipsiaNormal/low temperature in the presence of infection
Weight lossDry skinSunken eyes, soft eyeballsLethargy, coma
DKA (cont’d)DKA (cont’d)Lab findings –Serum glucose = >300mg/dLSerum ketones = positiveUrine ketones = positiveSerum pH = <7.35Serum HCO3 = <15mEq/LSerum potassium = ↑ with acidosis, ↓ with dehydration
BUN = >20mg/dL due to dehydration
Creatinine + >1.5mg/dL due to dehydration
DKA (cont’d)DKA (cont’d)Emergency management –Establish a patent airwayAdminister oxygen and NaHCO3 if ↓ pHPlace IV with large bore catheterAdminister NS per IV◦1L/hour for first 2-3 hours to stabilize blood pressure and ensure adequate urine output
IV fluid changed to D5 ½ NS when serum glucose reaches 250mg/dL
Urine output will decrease as osmotic diuresis effect of hyperglycemia is reduced
Careful monitoring of potassium level
DKA (cont’d)DKA (cont’d)Ongoing monitoring –Monitor blood glucoseAssess for hypokalemia◦Potassium will reenter the cell with insulin administration
Will need to decrease infusion rate when blood glucose is ≤300mg/dL
Anticipate order of D5W when blood glucose level is 250mg/dL◦Reduces risk of hypoglycemia
Assess for signs and symptoms of hypoglycemia◦Anxiety, behavior changes, confusion, headache, slurred speech
◦Blurred vision, hunger, cold sweats, tachycardia
Hyperglycemic-Hyperglycemic-Hyperosmolar Nonketotic Hyperosmolar Nonketotic
Syndrome (HHNS)Syndrome (HHNS)HHNS is a medical emergency with a high mortality rate
Hyperosmolar state caused by hyperglycemia◦Blood glucose = 800mg/dL◦Serum osmolarity = possibly >350mOsm/L
Exhibits no ketosisMay be seen in Type II Diabetes Mellitus
Often related to impaired thirst sensation or functional inability to replace fluids
HHNS (cont’d)HHNS (cont’d)Rapid progression◦Hours to days
Clinical manifestations –◦Polyuria, polydipsia, dehydration, aphasia◦Altered mental status (lethargy → coma)◦Postural hypotension, tachycardia◦Seizures, tremors, nystagmus, hyperreflexia
Treatment –◦Management is similar to DKA except HHNS requires greater fluid replacement as patient can have a 9-12L fluid deficit
◦Administer regular insulin at 0.1U/kg/hour until glucose level drops to 250mg/dL
HHNS (cont’d)HHNS (cont’d)Treatment (cont’d) –◦Fluid resuscitation
Administer 1-2L NS for 1st hour Follow with 1L/hour for the next several
hours Hyperglycemia will decrease with fluid
resuscitation May need to give low-dose insulin if
patient is hyperkalemic, acidotic, or in renal failure
◦Support airway, breathing, circulation
Differences between Diabetic Differences between Diabetic Ketoacidosis (DKA) and Ketoacidosis (DKA) and
Hyperglycemic-Hyperosmolar Hyperglycemic-Hyperosmolar Nonketotic Syndrome (HHNS)Nonketotic Syndrome (HHNS)
DKA HHNSOnset Sudden GradualSerum Glucose >300 >800Serum Ketones Yes NoSerum pH <7.35 >7.4Serum HCO3 <15 mEq/L >20
mEq/LSerum K Normal Normal
↑ with acidosis ↓ with dehydration
Serum Osmolarity Variable >350 mOsm/L
BUN ↑ ~ dehydration ↑Creatinine ↑ ~ dehydration ↑Urine Ketones Positive Negative
Gastrointestinal Gastrointestinal DisturbancesDisturbances
The stomach is acidic◦pH = 1.0 – 3.5
Fluid volume deficit possible◦Prolonged vomiting◦Gastric suction
Monitor for hypokalemia◦Potassium is present in gastric juices
Monitor for hyponatremia due to prolonged loss of sodium◦Suctioning◦Nasogastric irrigation with plain water
Fluid Volume DeficitFluid Volume DeficitTypes of fluid volume deficit –◦Isotonic fluid loss◦Hypertonic dehydration◦Third spacing
Isotonic Fluid LossIsotonic Fluid LossFluid and solute are lost equally◦Serum osmolarity remains normal
Intracellular water is not disturbedFluid loss is extracellular fluid◦Can quickly lead to shock◦Requires extracellular fluid replacement◦Emphasis is on increasing vascular volume
Isotonic Fluid Loss (cont’d)Isotonic Fluid Loss (cont’d)Causes –◦Hemorrhage
Loss of fluid, electrolytes, proteins, and blood cells results in inadequate vascular volume
◦Gastrointestinal losses Vomiting, NG suctioning, diarrhea, drainage
from fistulas/tubes
◦Fever, environmental heat, diaphoresis Profuse sweating causes water and sodium
loss through the skin
◦Burns Damages skin capillary membranes Allows fluid, electrolytes, and proteins to
escape into burned tissue area, leaving less vascular volume
Isotonic Fluid Loss (cont’d)Isotonic Fluid Loss (cont’d)Causes (cont’d) –◦Diuretics can cause excessive loss of fluid and electrolytes
◦Third spacing Fluid moves from the vascular space into
extracellular spaces
Treatment –◦Expand extracellular volume with isotonic IV fluids Increases circulating blood volume Restores renal perfusion
◦Provide blood transfusion for hypovolemia caused by hemorrhage
Isotonic Fluid Loss (cont’d)Isotonic Fluid Loss (cont’d)Treatment (cont’d) –◦Administer 1–2L bolus of isotonic fluid for adults Infuse in 30 minutes or less
◦Administer up to an additional 2–3L Improves urine output, blood pressure,
heart rate, and mental status
◦Infuse 20–30 mL/kg bolus of isotonic fluid for infants/young children to improve urine output, heart rate, respiratory rate, and mental status
Hypertonic DehydrationHypertonic DehydrationMore water is lost than solute◦ Creates a solute excess
Primarily sodium◦ Results in fluid volume deficit
Solute can also be gained in excess of water◦ Creates a similar imbalance◦ Most common with sodium or glucose
Serum osmolarity becomes elevated◦ Results in hypertonic extracellular
fluid◦ Pulls fluids into the vessels from the
cells by osmosis◦ Causes cells to shrink and become
dehydrated
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)Causes –
Inadequate fluid intake◦Inability to respond to thirst ◦May occur due to age (infants or the elderly), immobility, nausea, anorexia, dysphagia, or being NPO without fluid replacement
Severe or prolonged isotonic fluid losses◦Extracellular fluid becomes hypertonic and draws water from the cells Compensatory mechanisms become exhausted Conservation of water via the kidneys depleted Results in cellular dehydration
◦May occur with nausea/vomiting, diarrhea Loss of more water than solute
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)Causes (cont’d) –
Watery diarrhea◦Loss of more water than electrolytes
Diabetes insipidus◦Leads to massive, uncontrolled diuresis of dilute urine As much as 30L/day Can quickly lead to shock and death
◦Usually caused by a brain injury Damages/puts pressure on the
hypothalamus or pituitary gland◦Need to administer parenteral vasopressin
◦In a fluid volume deficit related to diabetes insipidus, urine will be pale, dilute, and high in volume
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)Causes (cont’d) –
Increased solute intake◦Excessive salt, sugar, or protein intake without a proportional intake of water
◦Increases plasma osmolarity◦Water is pulled from the cells, leading to cellular dehydration
◦Results in osmotic diuresis, which makes cellular dehydration worse Dangerous for patients with heart or
kidney problems
Conditions that lead to hypertonic dehydration –
Highly concentrated enteral or parenteral feedings
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)
Conditions that lead to hypertonic dehydration (cont’d) –
Improperly prepared infant formulas that are too concentrated
Hyperglycemia and/or diabetic ketoacidosis◦Excessive glucose and ketones in the blood
Increased sodium ingestion◦Ingestion of excessive amounts of seawater
◦Taking salt water tabletsExcessive use of osmotic diuretics
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)Clinical manifestations –
Thirst◦Early sign of dehydration◦Unreliable in the elderly and the very young
Concentrated urine◦Dark in color◦High specific gravity (normal is 1.010 – 1.030)
Low urine volume◦Normal output for adults is 30mL/hour
Dry mucus membranes◦When assessing mucus membranes, remember that environmental conditions can also cause dry lips
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)
Clinical manifestations (cont’d) –Dry skin◦Decreased turgor◦Decreased elasticity◦Tenting
Tissues stick together from interstitial fluid loss Unreliable in the elderly due to decreased
elastin Test on sternum, forehead, inner thigh, top of hip instead of arms and legs
Check infant skin over abdomen or inner thighs
Dry tongue with longitudinal furrowsDecreased tearing with dry conjunctiva
Sunken eyes
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)
Clinical manifestations (cont’d) –Sunken or depressed fontanel in infants less than 1 year
Flat neck veins and poor peripheral vein filling◦Jugular veins are nondistended even with the head of bed at <45 degrees
◦When the hand is placed lower than the heart, the hand veins normally distend in 3 – 5 seconds
Tachypnea
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)Clinical manifestations (cont’d) –
Low grade fever◦May be higher in severe dehydration
Mental status changes◦Often the first sign noticed in the elderly
◦Irritability, restlessness◦Drowsiness, lethargy◦Confusion
Decreased cardiac output◦Tachycardia (early sign in infants)◦Weak, thready pulse◦Cool extremities with delayed capillary refill
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)Clinical manifestations (cont’d) –
Postural hypotension when rising from lying to standing position◦Pulse increased by greater than 10-15 bpm
◦Fall in systolic blood pressure by greater than 10-15 mmHg
◦The greater the fall in blood pressure or rise in heart rate, the greater the fluid volume deficit
◦Weakness, dizziness, light-headedness, syncope
Frank hypotension◦Exists even when lying down◦Late sign in infants and young children
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)Clinical manifestations (cont’d) –
Acute weight loss◦2% body weight loss
Mild fluid deficit (thirst) 1 – 2 L fluid loss in an adult
◦5% body weight loss Moderate fluid deficit Signs and symptoms of dehydration
appear 3 – 5 L fluid loss in an adult
◦8% body weight loss Severe fluid deficit Frank hypotension 5 – 10 L fluid loss in an adult
◦>15% body weight loss Fatal >10L fluid loss in an adult
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)Parenteral therapy –
Hypovolemia and impending shock◦Isotonic fluids administered for adequate circulation and renal perfusion
◦Hypotonic solutions administered to correct cellular dehydration Given slowly to prevent cerebral edema due to
sensitivity of brain cells to hypotonicity
Hypervolemia◦Resulting from excessive sodium intake◦Administer a diuretic with hypotonic fluid to provide free water to cells while preventing vascular volume overload
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)Nursing interventions --
Monitor vital signs for changes in heart rate, blood pressure, and respiratory rate
Assess mental status◦Lack of improvement (or worsening) could indicate the infusion of hypotonic fluids is too rapid
Monitor urine output and concentration
Monitor IV rate◦Watch for fluid volume overload
Monitor I&OMonitor weight daily
Hypertonic Dehydration Hypertonic Dehydration (cont’d)(cont’d)Lab findings –
Hemoconcentration◦Plasma becomes concentrated to the red blood cells and urea particles
◦BUN would be highHigh urine specific gravity (>1.030)◦Kidneys conserve water while continuing to excrete solute
◦In cases of diabetes insipidus, specific gravity would be low (<1.010)
Increased plasma concentration◦Elevated serum osmolality (>300mOsm/kg)
◦Elevated serum potassium (>150mEq/L)
◦Elevated serum glucose (>120mg/dL)
Third SpacingThird SpacingThird spaces are extracellular body
spaces where fluid can accumulateThis accumulated fluid is useless
to the body◦Unavailable for use as reserve fluid◦Unable to transport nutrients
Common locations for third space fluid to accumulate –◦Tissue spaces (edema)◦Abdomen (ascites)◦Pleural spaces (pleural effusion)◦Pericardial space (pericardial effusion)
Third Spacing (cont’d)Third Spacing (cont’d)Causes –Injury or inflammation◦Increased capillary permeability allows fluid, electrolytes, and proteins to leak from the vessels Massive trauma Crush injuries Burns Sepsis Cancer Intestinal obstruction Abdominal surgery
Third Spacing (cont’d)Third Spacing (cont’d)Causes (cont’d) –Malnutrition or liver dysfunction◦Prevents liver from producing albumin, which lowers capillary oncotic pressure Starvation Cirrhosis Chronic alcoholism
High vascular hydrostatic pressure◦Pushes abnormal volumes of fluid from the vessels Heart failure Renal failure Other vascular fluid overload
Third Spacing (cont’d)Third Spacing (cont’d)Treatment –Osmotic diuretics are used to mobilize some of the fluid back into the blood vessels for elimination by the kidneys
Fluid Volume ExcessFluid Volume ExcessTypes of fluid volume excess –◦Isotonic fluid excess
Hypervolemia Edema
◦Hypotonic fluid excess Water intoxication
Risk factors that predispose individuals to fluid volume excess --◦Individuals of certain age
Elderly (due to ↓ heart and kidney function) Children < age 2 (due to immature kidneys) Children ages 2 – 12 years (due to unstable
regulatory responses)
Fluid Volume Excess (cont’d)Fluid Volume Excess (cont’d)Risk factors (cont’d) –◦Acute illness
Stimulates the stress response, which releases cortisol, ADH, and aldosterone → promotes water and sodium retention
◦Chronic illness Cardiovascular disease causes sodium
and water retention Reduces the pumping strength of the heart Reduces blood flow to the kidneys
Renal disease leads to abnormal retention of water, sodium, and potassium
◦Medications Long-term glucocorticoid therapy Drugs that act to retain sodium and fluids
Fluid Volume Excess (cont’d)Fluid Volume Excess (cont’d)Risk factors (cont’d) –◦Patients receiving IV fluids
Lab findings –Decreased hematocrit and BUN due to hemodilution◦Returns to normal once excess fluid is removed
Serum osmolarity is lowSerum sodium is very lowChest x-ray may show pleural effusionLow PO2 and PCO2Decreased pH due to respiratory acidosis (results from pulmonary edema)
Fluid Volume Excess (cont’d)Fluid Volume Excess (cont’d)Clinical manifestations –◦Peripheral edema
Legs, ankles, feet, and hands in ambulatory individuals
Sacrum and back in bedridden clients
◦Edema in the legs and feet Indicates local obstruction of veins Edematous skin is often tight and shiny
due to decreased circulation in swollen tissue
◦Puffiness in the face and around the eyes (periorbital edema) Associated with heart or kidney problems
◦Tense or bulging fontanels in children less than 1 year of age
Fluid Volume Excess (cont’d)Fluid Volume Excess (cont’d)Clinical manifestations (cont’d) –◦Pitting edema◦High central venous pressure
Distended neck veins when HOB is elevated Delayed hand vein emptying when hand is
raised above the heart for 3 – 5 seconds
◦Venous congestion Hepatomegaly Splenomegaly
◦Decreased urine output if cardiac or renal function is impaired
◦Weight gain of 3lbs over 2 – 5 days◦Full/bounding pulse, warm extremities
Fluid Volume Excess (cont’d)Fluid Volume Excess (cont’d)Treatment –◦Restrict fluid intake to 1,000 – 1,500mL/day
◦Maintain sodium restriction◦Maintain IV access◦Administer diuretics◦Increase protein intake to increase capillary oncotic pressure to pull fluid out of the tissues
◦Monitor respiratory status◦Monitor venous engorgement◦Monitor I&O, daily weight◦Assess for edema◦Assess neurologic status◦Monitor labs (BUN, HCT, sodium, ABGs, K+)
Isotonic Fluid ExcessIsotonic Fluid ExcessHypervolemia = gain of fluid and
solute (sodium) in proportional amounts◦Overall gain in the extracellular fluid without a change in serum osmolarity
Edema = excess tissue (interstitial) fluid throughout the body or specific to a body tissue or organ
Causes --◦Renal failure
Decreased excretion of water and sodium
◦Rapid infusion of isotonic fluid Exceeds the ability to compensate by the
heart and kidneys
Isotonic Fluid Excess (cont’d)Isotonic Fluid Excess (cont’d)Causes (cont’d) –◦Heart failure
Venous congestion Decreased renal blood flow leading to
decreased renal excretion of fluid and sodium
◦High corticosteroid levels, which results in sodium and water retention Therapy Stress response
◦High aldosterone levels, which results in sodium and water retention Stress response Adrenal dysfunction
Hypotonic Fluid ExcessHypotonic Fluid ExcessGain of more fluid than solute (sodium)◦Creates fluid volume excess◦Results in a deficit of sodium◦Serum osmolarity decreases
Causes hypotonic extracellular fluid that gets pulled into the cells
Cells swell, and cerebral edema occurs
Causes –◦Frequent use of plain water enemas◦Multiple nasogastric tube or bladder irrigations with plain water
◦Infusing hypotonic solutions too rapidly◦Use of improperly prepared infant formula
Hypotonic Fluid Excess Hypotonic Fluid Excess (cont’d)(cont’d)Causes (cont’d) –
◦Increased release of ADH SIADH causes the kidneys to retain large
amounts of water without retaining sodium Creates hypotonic extracellular fluid, which is drawn into the cells
Highly concentrated urine with low urine volume
Stress Surgery, anesthesia Opioid analgesics, pain Tumors of the lung or brain
◦Psychogenic polydipsia Compulsive drinking of excessive amounts
of water associated with psychiatric disorders (i.e. some types of schizophrenia)
Hypotonic Fluid Excess Hypotonic Fluid Excess (cont’d)(cont’d)Causes (cont’d) –
◦Severe or prolonged isotonic fluid volume excess Compensated by increased urine output Clients with heart failure, renal failure, and
diabetes are sensitive to excess fluid administration
Capillary Fluid MovementCapillary Fluid MovementHydrostatic pressure = the pushing force of a fluid against the walls of the space it occupies◦Generated by the heart’s pumping action
◦Varies within the vascular system
Capillary Fluid Movement Capillary Fluid Movement (cont’d)(cont’d)Oncotic pressure = the pulling force
exerted by colloids in a solution◦Albumin is a pulling force for water
Maintains normal serum oncotic pressure Maintains adequate vascular fluid volume
Causes of low capillary oncotic pressure --◦Injury or inflammation (trauma, burns, sepsis) Increases capillary permeability Allows fluids and proteins to leak from the vessels
◦Malnutrition or liver dysfunction (starvation, cirrhosis, chronic alcoholism) Prevents liver from producing albumin ↓ capillary oncotic pressure; fluid remains in
vessels
Capillary Fluid Movement Capillary Fluid Movement (cont’d)(cont’d)Starling’s Law
◦Filtration = movement of fluid into or out of the capillary, determined by the pushing and pulling forces
◦At the arterial end of the capillary, capillary hydrostatic pressure exceeds capillary oncotic pressure Fluid movement is from the capillary into
the tissue Carries nutrients to the tissues
◦At the venous end of the capillary, capillary hydrostatic pressure is less than capillary oncotic pressure Fluid movement is into the capillary from
the tissue Carries wastes away from the tissues
EdemaEdemaEdema = soft tissue swelling due to expansion of the interstitial volume◦Can be localized or generalized◦Fluid moves from the capillaries into the interstitial space and back again, carrying wastes with it
Increased capillary hydrostatic pressure◦Forces more fluid out of the arterial end of the capillary
◦Draws less fluid back into the venous end of the capillary
◦Results in edema as fluid accumulates in the tissues
Edema (cont’d)Edema (cont’d)Decreased capillary oncotic pressure◦Disrupts normal movement of fluid into and out of the capillaries
◦Weaker pulling pressure allows more fluid to be pushed out of the arterial end of the capillary
◦Unable to draw adequate amount of fluid back into the venous end of the capillary
◦Results in edemaCauses◦Hypertension◦Hypervolemia, lymphedema◦Renal failure
Edema (cont’d)Edema (cont’d)Lymphedema occurs when a blockage in the lymphatic system prevents lymph fluid from draining adequately; as the fluid accumulates, swelling continues◦Lymphatic obstruction◦Surgical removal of lymph nodes
Edema (cont’d)Edema (cont’d)Renal failure causes decreased renal perfusion leading to excess aldosterone in the blood◦Causes water retention that elevates the blood pressure
◦Increases hydrostatic pressure within the capillaries, which forces more fluid into the tissues
◦Results in edema
Congestive Heart Failure Congestive Heart Failure (CHF)(CHF)Inability of the heart to pump
enough blood to meet the metabolic needs of the tissues of the body
Associated with hypertension, myocardial infarction (MI), valvular disease
Left ventricular failure seen with pulmonary edema
Right ventricular failure seen with edema in the lower extremities
Failure tends to occur in both ventricles, so client will present with both peripheral and pulmonary edema
CHF (cont’d)CHF (cont’d)Fluid and electrolyte imbalances seen with CHF –◦Fluid volume excess
Decreased renal blood flow associated with decreased cardiac output
◦Hyponatremia ADH causes greater retention of water,
diluting serum sodium level◦Hypokalemia
Caused by diuretics, vomiting, and diarrhea
◦Respiratory acidosis Pulmonary congestion interferes with
carbon dioxide elimination from the lungs◦Metabolic acidosis
Anoxic tissue releases lactic acid
CHF (cont’d)CHF (cont’d)Fluid and electrolyte imbalances (cont’d) --◦Edema
Shift of intravascular fluid into interstitial tissue due to increase in hydrostatic pressure from excessive venous blood volume
Signs and symptoms –◦Fatigue due to decreased cardiac output◦Dyspnea
Cardiac output is inadequate to provide for body’s oxygen requirements
Paroxysmal nocturnal dyspnea occurs when client is in a recumbent position because edema fluid from the extremities returns to the bloodstream, increasing cardiac preload
◦Decreased urine output due to secretion of aldosterone and ADH
CHF (cont’d)CHF (cont’d)Signs and symptoms (cont’d) –◦Cough◦Tachycardia◦Peripheral edema◦Pulmonary edema
Increased pulmonary venous pressure forces serum and blood cells in the alveoli
Severe dyspnea, coughing, pink frothy sputum
◦Distention of the peripheral veins from elevated venous pressure Visible in the hands, face, and neck
◦Orthopnea Increased interstitial edema increases the
work of breathing Upright position fosters air exchange
CHF (cont’d)CHF (cont’d)Signs and symptoms (cont’d) –◦Nocturia
Oxygen demand reduced at night, decreasing renal constriction and increasing glomerular filtration rate
◦Cardiomegaly Hypertrophy of the myocardium that
helps to maintain stroke volumeNursing interventions –◦Lessen cardiac preload and afterload
Give diuretics per IV◦Administer ACE inhibitors (arterial vasodilators)
◦Restrict fluids◦Monitor I&O
Pulmonary EdemaPulmonary EdemaPulmonary edema is a medical emergency◦Place patient in high Fowler’s position◦Administer oxygen◦Administer IV morphine
Reduces preload through peripheral dilation Reduces afterload through decreased blood
pressure Reduces anxiety
Signs and symptoms –◦Tachypnea, dyspnea, labored breathing, cough, moist rales, decreased oxygen saturation
◦Third spacing as fluids are forced out of the vessels and into spaces that normally do not contain much fluid (ascites, pleural effusion)
◦Acute, rapid weight gain
Basic Classifications of Basic Classifications of Infusates Infusates
1. Crystalloids2. Colloids3. Hydrating solutions4. Hypertonic-hyperosmolar
preparations5. Blood or blood componentsCrystalloids -- Capable of crystallization Forms a solution Can diffuse through membranes Includes electrolyte solutions that
may be isotonic, hypotonic, and hypertonic
Classifications of Infusates Classifications of Infusates (cont’d)(cont’d)
Colloids –Cannot form a solution (does not dissolve)
Cloudy in appearanceRaises osmotic pressurePlasma or volume expanderTypes of colloids --◦Albumin◦Dextran◦Plasmanate◦Hetastarch◦Artificial blood substitute
Classifications of Infusates Classifications of Infusates (cont’d)(cont’d)
Hydrating Solutions (cont’d) –Supplements calorie intakeSupplies nutrientsProvides free water◦Maintenance◦Rehydration
Promotes effective renal outputFrequently used hydrating solutions◦Dextrose 2½% in 0.45% saline◦Dextrose 5% in water (D5W)◦Dextrose 5% in 0.45% saline◦Dextrose 5% in 0.2% saline◦Sodium chloride 0.45%
Classifications of Infusates Classifications of Infusates (cont’d)(cont’d)
Hydrating Solutions (cont’d) –Electrolytes in IV solutions are measured in mEq/L
Milliequivalents measure how many chemically active ions are present in a solution
Sodium chloride contains 154 mEq/L of sodium and 154 mEq/L of chloride, which equals 308 mOsm/L
0.45% NaCl (1/2 strength saline) has 77 mEq/L of sodium and 77 mEq/L of chloride, which equals 154 mOsm/L
Classifications of Infusates Classifications of Infusates (cont’d)(cont’d)
Dextrose Solutions –Manufactured as a percentage of the concentration in water or sodium chloride
Expressed as the number of grams of solute per 100mL of solvent
5% dextrose in water solution contains 5g of dextrose in 100mL of water
Isotonic InfusionsIsotonic InfusionsD5W◦Osmolarity = 252.52 mOsm/L◦Best solution for hydration
Isotonic in bag Hypotonic once dextrose metabolized
◦Does not contain electrolytes◦Not given to patient with increased intracranial pressure
◦ADH secretion is increased as a stress response to surgery Use cautiously in early post-operative
period to prevent water intoxication◦Hypokalemia can occur due to cellular use of glucose Potassium shifts from the extracellular
fluid to the intracellular fluid
Isotonic Infusions (cont’d)Isotonic Infusions (cont’d)D5W (cont’d) --◦Use cautiously in patients with signs of fluid overload and congestive heart failure Dehydration with rapid infusion due to
osmotic diuresis◦May alter insulin/oral hypoglycemic needs in diabetics Contraindicated in diabetic coma
◦Should not be used in patients with allergies to corn and corn products
◦Medication incompatibilities –Ampicillin DiazepamErythromycin Fat emulsionsPhenytoin sodium
ProcainamideSodium bicarbonate Warfarin
sodium Whole blood Vitamin B12
Isotonic Infusions (cont’d)Isotonic Infusions (cont’d)0.9% normal saline (NS)◦Osmolarity = 308 mOsm/L◦Only infusate compatible with a blood infusion
◦Maintains patency of heparin locks◦Used as a diluent for medications◦Replaces extracellular fluid losses by expanding intravascular space
◦Corrects hyponatremia◦Used to treat hypovolemia◦Can cause intravascular overload
Monitor I&O
◦Can cause hypokalemia Saline promotes potassium excretion
Isotonic Infusions (cont’d)Isotonic Infusions (cont’d)NS (cont’d) –◦Can cause hypernatremia
Sodium may be retained in intraoperative and early post-operative situations
Excessive sodium retention when used with glucocorticoids
Contraindicated in patients with edema and sodium retention
◦Does not provide free water or calories
◦Used with caution in certain patients Decreased renal function Altered circulatory function Elderly
Isotonic Infusions (cont’d)Isotonic Infusions (cont’d)NS (cont’d) –◦Medication incompatibilities –
Amphotericin B (antifungal)Chlordiazepoxide HCl (Librium)DiazepamFat emulsionsLevarterenol (norepinephrine)MannitolMethylprednisolone sodium
succinate(Solu-Medrol)
Phenytoin sodium
IV Fluid RemindersIV Fluid RemindersThe body is in a state of homeostasis when the serum osmolarity is the same as other body fluids◦Approximately 280 – 300 mOsm/L
To change the osmolarity, glucose and/or electrolytes must be added to the solvent◦Increases the total number of particles in the solution
◦Increases osmotic pressure
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