Fundamentals session 6: fluid and electrolytes, blood therapy, and the end of IV

Hey all, this session was filled with a ton of material. overall I do not think that it was overly difficult material, but there was quite a bit of it. The main foci were the administration of blood products, the end of IV, and fluid and electrolytes. A lot of this material is common sense, and in some cases review, so take a quick look at it and hopefully you can make it though my errors!

-Peter

 

Fundamentals

 

Beginning of test three material:

 

    • containers: we are moving towards plastic containers
      • glass is non collapsible
      • this may have a vent if non collapsible
    • crystalloids: fluids that are clear
      • isotonic
      • hypotonic
      • hypertonic
    • colloid: contain proteins or start molecules
      • albumin, blood products, hetastarch
    • examples of IV solutions
      • D5 W, 0.9%NaCl, 0.45% NaCl
    • needleless systems
      • heprin lock, buff cap
      • Positive pressure cap (possi-flow)
    • Admin sets
      • spike bag w/out breaking sterility
      • prime line to take out air
    • Infusions
      • intravenous bolus (less than 5min)
        • also called a push!
      • IV infusion
        • continuous
        • intermittent – can be a secondary bag or piggy back.
      • Primary – maintenance fluids
      • secondary bag – infuses through the primary solution (piggy back)
        • higher bag will infuse first.
      • flow rate: IV pump or manual roller clamp
        • factors that affect flow – kink in the line, IV patency, clogged air vent (in a bottle), height of IV bag, hight of IV in patient
        • VTBI: volume to be infused
      • the nurse is responsible for the IV line!
      • when do we change the IV solution and line?

 

  • lipid emulsion w/out TPN (change with each bag) w/ TPN every 24 hours. Max is 24 hours

 

      • change bag with line
      • Max line change time for any solution 96 hours (4 days)

 

Fluid balance and electrolytes nursing assessment and intervention

  • ECF: extracellular fluid
  • ICF: intracellular fluid

 

    • RASS system controls the blood pressure and changes the fluid amounts in the different areas.
    • daily weight – have it a same time each day

 

  • one liter = 1 kg

 

      • loss 6.6 lbs means about 3 liters of fluid was removed from the body
    • I/Os – ins and outs
    • Basic metabolic panel: BMP
      • important lab values to know: Na, K, Ca, Glu, BUN, creatinine
    • Na- 135-145 mEq/L
      • need to know for NCLEX, but in the hospital there are usually a normal limits guide next to the lab value.
    • K – 3.5 – 5

 

  • Always when giving a bolus of K, use an IV pump.

 

    • don’t exceed 10-20 mEq/hr infusion
  • Ca – 8.5 – 10.1 mg/dL
  • Mg – 1.5 – 1.9 mEq/L
  • Phos – 1.7 – 2.6 mEq/L

 

fluid volume deficit – nausea, vomiting,

  • s/s weight loss, thirst, orthostatic hypotension
  • interventions – start with the least invasive (PO) and move to more invasive, (IV)

 

fluid volume excess – dt cardiac, liver, or kidney dx

  • I/O is very important
  • s/s edema, JVD, tissue tugor
  • lab studies – CBC, serum electrolytes, urine pH and specific gravity, ABG
  • connection to respiratory distress is the fluid will back up from the heart into the lungs.

 

management of Fluids and electrolytes

  • I/O
  • weight
  • calorie count
  • LOC
    • Changes in LOC are always important.
  • skin tugur

serum albumin – >½ body’s total protein,

prealbumin – short term and is better at assessing current values

 

Ascites – over all body edema

  • paracentesis: pulling fluid out of a patient w/ needle and vacuum bottle

Fluid volume deficit:

(hypovolemia)

increased HR

decreased BP

increased RR

decreased UO

decreased skin turgor

decreased weight

Restlessness, lethargy

Assess electrolytes

Give fluids

 

Fluid volume excess

(hypervolemia)

increased HR

increased BP

increased weight

increased edema

Neck vein distention

Crackles

Headache, confusion

Assess electrolytes

Remove fluids

 

electrolyte replacement

  • PO or IV
  • use caution
  • normal saline is not considered replacement of electrolytes

 

fluid restriction

  • ex. 2000ml FR apply evenly over 24 hours
  • ice melts to half its volume
    • 8 oz = 240ml = 120ml when melted (record this number)

 

I/Os – totalled over 24 hrs, monitored every hr (ICU) or 8 depending on unit

 

NG tube – nasogastric tube – suction out of the stomach for GI rest.

  • falls into the OUTput category usually but can be input

 

Labs

  • usually pulled by phlebotomus
  • there may be a specific order to the drawing of labs
  • administering the wrong blood type can be fatal
    • cross match and type of blood needs to be redone every three days.
    • optimally ¾ filled with blood in the draw tube
    • labeling labs is extremely important.
    • performing veno puncture
  • critical results
    • promptly communicate to caregiver, caregiver writes it down and reads it back.
    • communicate to LIP within 30 min.

 

IV therapy: blood product administration

 

why give blood products?

 

sources of blood products

  • donor
  • Autologous: donor is self
  • Autotransfusion: returns own blood to self

 

whole blood is the highest volume

  • one unit = 500ml

PRBC- packed red blood cells

  • 80% of plasma removed
  • one unit = 250 ml

WBC

Platelets (thrombocytes)

  • for thrombocytopenia

 

ABO is carried on RBC

    • O- is universal donor
    • AB+ is universal recipient
    • -Rh
    • +Rh
    • Know comprable blood types

 

  • double check blood type with two licensed RNs
  • student cannot give blood products, only spike bag

 

 

giving products:

  • Prime IV line with normal saline
  • double check all ID information
  • PRB can take 4 hr to infuse 1 unit
  • Reaction to reaction to blood type will be a change in vitals
    • take baseline before and 15mins after
    • s/s: facial flushing, fever, HTN, increased HR,
    • Febrile reaction
      • hypersensitivity to donor WBC
      • s/s fever, chills, headache, malaise
    • allergic reaction
      • s/s flushing, hives (urticaria), wheezing, rash
    • Septic reaction
      • fever chills, vomiting, diarrhea, and hypotension

 

Respiratory compromise Interventions

 

use the ABC’s to prioritise patients

 

Shortness of breath (SOB) can be caused by many things

 

Breathing quality and pattern

 

circulation

  • change in LOC may be one of the first critical signs
  • pulse oximetry
  • color
  • VS

 

Pulmonary edema

  • ronchi, crackles, hypoxic

Pulmonary embolism

  • hypoxic, pain on inspiration, history of DTV,

pneumonia

  • fever, hypoxic

 

ABG’s are the most current O2 status

  • very invasive, sticking the artery

 

Sa02 – arterial O2 (hypoxia)

Sp02 – Hemoglobin saturation %

Pa02 – tissue oxygenation (hypoxia)

 

Deep breathing and coughing can prevent atelectasis

 

incentive spirometer – inspire slow and steady and record the number that it maxes out on.

 

 positioning and ambulation

  • tripod: leaning on hands or elbows while pt is sitting or standing
  • fowler’s position 45 – 60 degrees
    • semi fowler’s 30 degrees
    • high fowler’s 90 degrees

MDI – metered dose inhaler

  • spacer can hold the med and inhale when ever

 

aerosol given via nebulizer

  • most common is bronchodilators

 

O2 therapy

  • prescribed in terms of liter flow or concentration
  • can be used without an order if the patient is in immediate need
  • use the least amount necessary to prevent the drying of the nasal membranes
  • low flow – 1-6L/min of 02
  • high flow – 10-15L/ min

 

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