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!
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
- 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
- intravenous bolus (less than 5min)
- also called a push!
- IV infusion
- 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?
- intravenous bolus (less than 5min)
- 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
- calorie count
- 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:
decreased skin turgor
Fluid volume excess
Neck vein distention
- PO or IV
- use caution
- normal saline is not considered replacement of electrolytes
- 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
- 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
- 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
- for thrombocytopenia
ABO is carried on RBC
- O- is universal donor
- AB+ is universal recipient
- Know comprable blood types
- double check blood type with two licensed RNs
- student cannot give blood products, only spike bag
- 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
- change in LOC may be one of the first critical signs
- pulse oximetry
- ronchi, crackles, hypoxic
- hypoxic, pain on inspiration, history of DTV,
- 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
- 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