“ Be a doer not a me too-er.”

Dr. Greg House

All liquids taken by the patient

Oral fluids Water, milk, juice, soft drinks, coffee, tea, cream, soup, sherry, wine

Water taken with medications

Ice chips – approximately ½ their volume

Foods that become liquid at room temperature

Ice cream, sherbert, custard, gelatin, pudding, popsicle

soup, & broth, ice water, frozen yogurt

A full cup of ice is equal to 1/2 cup of water (120cc).

Note: do not measure foods that are pureed; these are solid food prepared in a different form

Tube feedings Remember to include the 30-60 ml. water rinse at the end of intermittent/ continuous feedings

Parenteral fluids IVF, blood & its components

Total Parenteral Nutrition (TPN)

A patient has recorded the following on a sheet of paper at the bedside:

Breakfast: eggs, toast, one cup of coffee (coffee cups at this hospital contains 6 ounces); small orange juice (4 ounces)

      

Lunch: sandwich, apple, glass of tea (glasses at this hospital contains 8 ounces)

Dinner: chicken, broccoli, rice, 2 glasses of tea

Between meals: 4 glasses of water 1000 mL of D5 W infusing IV at

30 mL/hour

Calculate the Intake for a 12 hour shift: Note you need to covert ounces to mls.

Dextrose in Dextrose in H2O SolutionH2O Solution

Other NameOther Name ConcentratioConcentrationn

Dextrose 5 Dextrose 5 % in water % in water

D5WD5W IsotonicIsotonic

Dextrose 10 Dextrose 10 % in water% in water

D10WD10W HypertonicHypertonic

Saline Saline solutionsolution

Other NameOther Name ConcentratioConcentrationn

0.45 % NaCl 0.45 % NaCl (Half NS)(Half NS)

½ NS½ NS HypotonicHypotonic

0.9 NaCl0.9 NaCl NSNS IsotonicIsotonic

3-5% Sodium 3-5% Sodium ChlorideChloride

3-5 % NS3-5 % NS HypertonicHypertonic

3-5% NaCl3-5% NaCl

Dextrose in Dextrose in Saline Saline SolutionSolution

Other NameOther Name ConcentratioConcentrationn

Dextrose 5% Dextrose 5% in .9 NaClin .9 NaCl

D5 0.9% NaClD5 0.9% NaCl HypertonicHypertonic

D5 0.9% NSD5 0.9% NS

D5NSD5NS

Dextrose 5% Dextrose 5% in .45% NaClin .45% NaCl

D5 0.45% D5 0.45% NaClNaCl

HypertonicHypertonic

D5 0.45% NSD5 0.45% NS

D5 1/2 NSD5 1/2 NS

Multiple Multiple Electrolyte Electrolyte SolutionsSolutions

Other NameOther Name ConcentratioConcentrationn

Lactated Lactated Ringers Ringers SolutionSolution

LRLR IsotonicIsotonic

Dextrose 5% Dextrose 5% in Lactated in Lactated Ringers Ringers SolutionSolution

D5LRD5LR HypertonicHypertonic

Isotonic Solution – extracellular volume replacement; FVD secondary to excessive vomiting

Intravenous medications

IV medications that are prepared with solutions (ex. NSS)

Ex. Tobramycin sulfate 80 mg. in 50 ml.

Catheter or tube irrigants

Fluid used to irrigate urinary catheters, NGT,

intestinal tubes

Urinary outputAfter each voiding, pour the urine in a measuring container,

Observe the amount &

and record it & the time of voiding on the bedside I & O form

Retention catheter – note & record the amount of urine at the end of the shift then empty the drainage bag.

If the client is incontinent of urine or is extremely diaphoretic, estimate and record these outputs

“Incontinent X 3” or “Drawsheet soaked in 12 inches diameter.”

Weigh diapers or incontinent pads that are dry, then subtracting this weight from the weight of soiled items.

1 gram = 1 ml. of urine

If the urine is frequently soiled with feces, record the number of voiding instead.

Vomitus & liquid feces

Time & type of fluid must be specified

Diaphoresis Record “Perspiring profusely.” or Perspiration ++++

Check agency policy on this

Tube drainageGastric, intestinal drainage

Wound drainage & draining fistulas

Recorded by counting the type & number of dressings; linen saturated with drainage

Measuring the exact amount of drainage collected in a vacuum drainage system

( Hemovac, Jackson Pratt drain )

Amount of input & output must be measured in 24 hrs.

Recorded in I & O sheet

Input & Output must be recorded at the end of every nursing shift

Nursing procedure

obtaining an accurate data base

evaluating client’s hydration status

Following a surgical procedure

Febrile clientsClients with fluid restrictions

Client under diuretics/IVF therapy

Chronic CP/Renal Illness

Unstable Client

The patient recorded the following amounts voided on the sheet of paper: 400 cc at 7:00 am; 100cc at 10:00 am; 200cc at 12 noon; 150 cc at 2:00 pm; 400cc at 6:00 pm. The nurse emptied 300cc from a JP tube. The patient vomited 100cc at 4:00 pm What is the total output for the 12 hour shift?

Laboratory StudiesSerum/Urinary electrolyte levels

Hematocrit (Hct)

CreatinineBlood Urea Nitrogen (BUN)

Urine Specific Gravity

5 % weight gain – moderate FVE

EyesSunken, dry conjunctivae,

Decreased tearing - FVD

Periorbital edema, papilledema – FVE

Throat & MouthDry mucous membrane,Dry cracked lips, decreased salivation - FVD

CV SystemFlat neck veins, slow venous filling – FVD

Distended neck veins - FVE

Increase PR, weak pulse, low BP – FVD

Bounding pulse, 3rd heart sound, hypertension - FVE

Respiratory SystemCrackles, increase RR – FVE

GI SystemSunken abdomen – FVDDistended abdomen – 3rd space syndrome

Renal systemOliguria/Anuria – FVDEdema (dependent areas-sacrum, back, legs - FVE

SkinDecreased body temperature, dry frosted skin, cold clammy skin, inelastic skin turgor - FVD

single most important indicator of fluid status

Must be done:1.Same time each day2.Same scale after the

client voids

3.Client must wear same clothes

4. If bed scale is used, must have same number of sheaths

If client is under fluid restrictions, allowed to take 30 ml. of water

Allow half of the allotted oral fluids between 7 am - 3 pm.

Why ?

Client is most active at that time

Received 2 mealsTake most of their oral medications

Urine is liquid waste product of the body secreted by the kidneys by a process of filtration from blood and excreted through the urethra.

Change in urine volume – significant indicator of fluid alterations or kidney disease

Plastic receptaclesUrinalsbedpans

Urimeter can hold 100-200 ml. of urine, after measuring can be drain into a receptacle or urine bag for disposal

To measure urine volume, use separate plastic graduated measuring receptacle

Normal Urine Output 30 cc./hr.1500 ml./day

Hourly urine output < 30 ml. for more than 2 hrs. is a cause for concern

< 0.5 ml/kg./hr. for 2 consecutive hrs

Daily urine output of 2000-2500 ml. daily-

Must be reported to the physician

Oliguria – small volume of urine

Urine output = 100-500 ml./24 hr

Anuria – absence of urine output

Output < 50 ml./24 hr.

To determine whether the fluid output is proportional to intake or there is a change in the client’s fluid status

The nurse compares the total 24 hr. fluid output measurement with the total fluid intake measurement

Compares both to previous measurements

Urinary output = Amount of fluids ingested

Urine output = 1500-2ooo ml. in 24 hrs.

or 40 – 80 ml. in 1 hr.

RouteRoute Gain Gain (ml.)(ml.)

RouteRoute Loss Loss (ml.)(ml.)

H2O H2O (food)(food)

10001000 SkinSkin 500500

H2O H2O (oxidation(oxidation))

300300 LungsLungs 300300

H2O H2O (liquid)(liquid)

12001200 FecesFeces 150150

KidneysKidneys 15001500

TotalTotal 25002500 == 25002500

Nursing Responsibilities:

1. No room for error in calculating dosages

2. Check math work with another nurse

3. Work problems systemically & carefully on paper

4. Recheck calculations

5. Is the answer reasonable?

Metric Apothecary 60 mgs 1 gr. 1000 mgs 15 gr. 4 grams. 1 dram 30 grams. 1 oz. .45 kg 1 lb. 1 kg. 2.2 lbs.

Formula when Preparing Solid or liquid forms

Dose Ordered X Amount on hand = Amount Dose on hand to

administer

Dose ordered – amount of medication prescribed

Dose on hand is the weight or volume available in units supplied by the pharmacy

Amount to administer – the actual amount of medication the nurse will administer;

expressed in the same unit as the amount on hand

Formula :Volume/Time x drop factor = drop rate

Volume/cc/hr = Time

The order reads : 1000 ml D5W to run for 8 hrs. Drop factor is 10.IV correctly set at 21 gtt./min. After 4 hrs. 500 ml. would be infused. However after 4 hrs. You find 600 ml. remaining. You must compute a new flow rate for 600 ml. to run for remaining 4 hrs.

If you are going to catch up the lost 100 ml. in 1 hr. can be very dangerous.

Do not do it!The flow rate must be

recalculated if the IV is off schedule.

Pediatric dosage refers to the determination of the correct amount,

frequency & the total # of doses of a medication to be administered to a child or infant.

Young’s Rule – 2 yr. old or older

Up to 12 years oldFried’s Rule – for infants less than 2 yrs. old

Clark’s Rule – uses child’s wt. to determine proper dosage

Estimating Body Surface Area – uses a nomogram

employs weight in determining the dose C.D. = Weight in lbs. X Adult dose

150

What is the dose of a drug for a 45 lb. child if the average adult dose of the medication is 15 mg ?

Child’s dose = 45 x 15 = 4.5 mg. 150

infants up to 2 years oldC.D. = Age in months x Adult

dose 150

What is the dose for a 9 month old infant If the average adult dose

is 35 mg?

Child’s dose = 9 x 35 = 2.1 mg 150

for children 2 years & older

C.D = Age (yr) x Adult dose

Age (yr) + 12

The adult dose of the drug is 7 grains. What is the dose of a 3 yr. old child?

Child’s dose = 3 x 7 gr. = 1.4 gr

3 + 12

finding the surface area in square meters (m2)

C.D. = BSA of Child (m2) x Adult dose

1.73 (m2) Average Adult B.S.A = 1.73 m2

ac – before mealsad lib – freely, as desiredbid – twice a dayc – withcap – capsuledil – dilute, dissolve

elix – elixirg, gm, Gm – gramgr – graingtt – droph – an hourhs – at bedtime (hour of sleep)IM – intramuscularIV – intravenouskg or Kg – kilogram

L,l – litermcg – microgrammg – milligramOD – right eyeOS – left eyeOU – both eyespc – after meals

po, PO – by mouthprn – when neededq – everyqAM – every morningqh – every hourqhs – every night at bedtimeqid – 4 times a day

qod – every other day Rx – take s – without Sc, sc, SQ – subcutaneous Sig or S – label stat – at once sup or supp – suppository tid – three times a day

60/M with obstructive jaundice due to a pancreatic head mass.

Prothrombin time is deranged. Patient will be needing Vitamin K.

I forgot what preparation of Vitamin K to give?

Is it Oral or Parenteral?Which is better?

Equipment:Syringes – consists of barrel, plunger & tip

Tuberculin syringe ( 1 ml.) – for small doses of epinephrine, intradermal skin tests & subQ meds

Measured in ml. long lines represent .1 ml.; shorter lines .05 ml. & shortest lines .01 ml.

3 ml. Syringe – most frequently used; for most IM injections; calibrated in ml. or cc.

Insulin syringe – calibrated in units; U 100 syringe holds 100 units/ 1 ml.; U 50 units/.05 ml.

Needles – hub, shaft & beveled tipNeedles – hub, shaft & beveled tip

Lumen – opening at the needles beveled end

Gauge – size of the diameter of the inside of the needle’s shaft; the smaller the gauge the larger the diameter of the needle

Needle length – selected based on the depth of the tissue into which the medication is to be injected

Intradermal injections – 3/8 - 5/8 inch

IM – 1-1 ½ inchSubQ – 5/8 – ½ inch

Needles should never be recapped to avoid needle stick injuries

Scoop technique

Formula when Preparing Solid or liquid forms

Dose Ordered X Amount on hand = Amount Dose on hand to administer

Example: The physician orders 15 mgs of diazepam (Valium). The nurse has Valium tablets that contain 5mg/tablet.

D/S x Q 15 mgs/5 mgs x 1 tab = 3

tablets

The physician orders 40 mgs of furosemide (Lasix). The nurse has an ampule of furosemide labeled Lasix 20 mg/ml.

D/S x Q 40 mg/20 mg x 1 ml. = 2 ml.

Formula :

Volume/Time x drop factor = drop rate

Volume/cc/hr = Time

Pediatric dosage refers to the determination of the correct amount, frequency & the total # of doses of a medication to be administered to a child or infant.

Young’s Rule – 2 yr. old or older

Up to 12 years old

Clark’s Rule – uses child’s wt. to determine proper dosage

Provide fluid & electrolyte maintenance, restoration & replacement

Administer medications & nutritional feedings

Administer blood & blood products

Administer chemotherapeutic drugs

Administer PCAKVO for quick access

Isotonic – exerts the same osmotic pressure as that of plasma

Normal saline 0.9%Lactated Ringers

Blood components (Albumin 5%, Plasma)

5% dextrose in water (D5W)

Hypotonic – exerts less osmotic pressure than that of blood plasma; forces water movement into cells to reestablish cellular equilibrium; cells expand or swell

Half-strength normal saline (0.45%)

One-third sodium chloride (0.3%)

Hypertonic – exerts higher osmotic pressure than that of plasma; draws water out of the cells into the extra cellular compartment to restore equilibrium; cells shrink

Dextrose 5% in normal saline 0.9%

Dextrose 5% in half-strength normal saline

Dextrose 10% in waterDextrose 20% in water

Saline 3% & 5%Hyperalimentation solutions

Dextrose 5% in lactated Ringer’s

Albumin 25%

Large –Volume Infusions – safest, easiest; medications are diluted in large volumes 500 ml. or 1000 ml. (Vitamins & KCl)

Intravenous bolus “Push” – introducing a concentrated dose of medication

directly into the systemic circulation; most dangerous method for administering medications; before administering a bolus the nurse confirms placement of the IV line.

Volume-Controlled Infusions – fluid within a secondary fluid container separate from the primary fluid bag.2nd container connects directly to the primary IV line.

Piggyback – a small IV bag or bottle connected to short tubing lines that connects to the upper y-port of a primary infusion line.

small bag or bottle is set higher than the primary infusion bag or bottle

Tandem – small IV bag or bottle connected to a short tubing line to the lower y-port of a primary infusion line.

Placed at the same height as the primary infusion bag or bottle

Tandem & mainline infuse simultaneously

Volume-Control Administration (Volutrol, Buretrol, Pediatrol, Solu-set) small containers (50-150 ml.) that attach just below the primary infusion bag or bottle.

Miniinfusion pumps – battery operated that allows medications to be given in very small amounts of fluid 95-60 ml.) within controlled infusion times using standard syringes.

Intermittent Venous Access (Heparin lock or Saline lock) – an IV catheter with a small chamber covered by a rubber diaphragm.

access must be flushed with a solution to keep it patent.