Week 1 - Fluid & Electrolyte Balance I

Intravenous access

pathway directly into the intravascular fluid space either in a peripheral vessel(PIV) or a central vessel (CVAD).​

Vascular Access Device Selection​

• Duration: PIV for shorter, CVAD for longer​

• Patency: PIV more at risk of loss of patency ​

• History of vascular access and comorbidities: difficult prior access, skin, vessels​

• Type of therapy: vesicant/irritants, pH ​

• Patient’s preference ​

*Always select smallest gauge appropriate (typically 22 for PIV) and minimumlumens

Phlebitis

inflammation of vessel wall​

• warmth, pain, swelling, redness at insertion site

Infiltration + Extravasation 

• Infiltration: Leakage of non-vesicant (non-irritating) solutions or medications into surrounding tissue.

• Extravasation: Leakage of a vesicant (irritating or tissue-damaging)

• Pain, Swelling, cool to touch

• vesicant = Can cause severe tissue damage, blistering, or necrosis

PIV-related thrombosis

clotting at/from insertion site ​

• Swelling, pain, difficulty moving limb at insertion site, if thrombosis moves --> pulmonary embolism (decreased O2, SOB)

PIV – related bloodstream infection:

infection originating from device —> catheter, insertion site, IV system​

• Pain, swelling, fever, purlent drainage at site

• usually localized infection, may progress to bloodstream infection

CVAD infection much more serious = systemic infection 

VAD Selection​: PIV

• Access in upper extremity ​

• Short term therapy (<7 days)*​

• Monitor for repeated failed/loss access = may consider switching to another VAD or site

VAD Selection CVAD​

• Use when suitable PIV access is unavailable ​

• Long term therapy ​

• Suitable for vesicant/irritant medications/nutrition

Central Venous Access Devices​

• Inserted into a large vein in the central circulation system, where the tip of the catheter terminates in the superior vena cava (SVC) that leads to an area just above the right atrium​

• Inserted by HCP with specialized knowledge ​

• Often inserted with ultrasound guided technique

Common CVADs:

• Peripherally Inserted Central Catheter (PICC)​

• Non tunneled CVAD ​

• Tunneled CVAD​

• Implanted CVAD

PICC

• Enters body on upper arm, catheter runs to superior vena cava ​

• VERY common in clinical settings ​

• RNs can insert and remove(specialized skill!)​

• Medium term use

Non-Tunneled CVAD​

• Enters body directly at vessel site (internal or externaljugular, subclavian, or femoralvein), catheter runs to superior vena cava ​

• Catheter outside of the body at the insertion site ​

• Common in critical care patients (shorter term)​ = emergency access areas 

• NOT appropriate to leave in —> pts wont be discharged with, inconvienent

• HIGH risk of infection = short distance outside to circulation 

Tunneled CVAD

• Tunneled (Hickman, larger or Broviac, smaller) ​

• Proximal end tunnelled subcutaneously from the insertion site and brought out through the skin at an exit site. Antimicrobial cuff​ (under skin, not at enterance)

• Long term use​

Implanted CVAD​

• Implanted (Port-A-Cath)​

  • port = small disk, top is self-sealing silicone septum 

  • catheter connected to port —> central vein 

• Device may be placed in the chest, abdomen, or inner aspect of the forearms​

• under skin, not visible (may appear as bump, palpable) 

• Accessed by special needle(specialized skill!)​ = after needle removed no dressing needed

• Long-term use​ (longest out of all CVAD) 

CVADs - Infection 

• Infections=high risk for sepsis! ​

• Patient populations​

  • peds, oncology (chemo, blood draws), ICU, immunocompromised

• PPE ​

  • gloves for routine access, dressing change

  • mask, gown, gloves insertion, per protocol

• Anti-Microbials

  • caps, dressings

CVADs - Infection Risks and Signs

• INFECTIONS = HIGH RISK FOR SEPSIS = directly into bloodstream

• Maintain sterile technique when using CVADs—remember they are a directportal to the central vasculature

• What signs and symptoms of infection should you notice? Swelling,redness, purulent drainage, pain, fever ​

• If you notice S/S of infection – notify the healthcare provider!​

• You might also notice signs and symptoms of phlebitis – redness, redtracking vessels from device, swelling – if you notice these, stop the infusion and notify the provider!

Using a CVAD: placement + flush

• consider placement (confirmed placement?)​

• Flush prior to and after use with pre-filled 10mL syringe​

  • prior to ensure patency, after to ensure meds r delivered

• Do NOT push past resistance​

  • could be clot = stroke, or pushed again vessel wall (damage) 

• Report resistance to provider (may order a medication that is instilled into the CVAD to try and breakdown a clot in the CVAD prior to reinsertion) ​

  • TPA or TNK 

Using a CVAD: Lock

• “Lock” with heparin **​

• When CVADs are having a period of unuse – say between treatments, the CVADs can be locked with a heparin flush that is left in the CVAD tubing to prevent clotting and occlusion ​

• keeps positive pressure, overwise blood can back up into line and clot 

• Look for labels/orders before use!

• heparin NOT FLUSHED!, must be aspirated out then flush w saline 

CVAD - Air emboli

• Findings: Sudden onset chest pain, SOB, dizziness ​

• LARGE bolus of air, can obstruct circulation

• Action: IMMEDIATE: L lateral Trendelenburg (trap air in R atrium, to prevent movement to brain, heart, lungs, etc), and administer O2​

  • head down, left side 

  • air bubble made of nitrogen, O2 causes conc gradient, nitrogen from bubble into blood (smaller bubble) 

  • aspirate air out if needed (large)

The nurse is providing health teaching to the parents of a child withleukemia about their central venous catheter device and it’sassociated care. Which of the following statements made by theparents indicate a need for further health teaching?​

​

A“We will cover the site with a transparent adherent dressing.”​

B“We will report if there is swelling or drainage at the exit site.”​

C“We will use clean technique when changing the dressing.”​

D“The nurse will flush the device before and after administration.”

C = sterile technique 

A nurse is assessing a client with a central venous access device(CVAD). Which of the following findings should the nurse identify aspossible signs of a CVAD-related infection? ​

Select all that apply.​

A. Redness and warmth at the insertion site​

B. Fever and chills​

C. Increased capillary refill in the extremities​

D. Purulent drainage from the catheter site​

E. Sudden onset of hypotension​

F. Bradycardia and cool skin

A, B, D, E

• Will be decreased cap refill ​

• Signs of septic shock --> INCREASE HR, RR, progressing to LOW BP ​

• Bradycardia + cool skin --> end stage sepsis

Sodium (135-145 mmol/L):

• closely linked to fluid balance (BP, volume), nerve/muscle func

• correct slowly to prevent cerebral edema

  • Sodium replacement must be slow --> water follows sodium --> can leave to fluid overload (cerebral edema)

• mild imbalances are corrected with isotonic solutions = replaces both sodium + fluid w/o shifting fluids in/out cell

• signficant imbalances can be corrected with hypo/hypertonic sodium containing fluids​

Potassium (3.5-5 mmol/L):

• potassium maintains resting electrical charge for cardiac cells (too high = less excitable, too low = hyperexcitable), muscle elec activity (contract), pH

• high alert

• concern for cardiac instability

• mild imbalances may be corrected with oral replacement or excreting medications (diuretics)

• significant imbalances may be corrected slowly (not IV push!) with IV potassium

• connect to cardiac monitor​

What do we want to know about electrolyte imbalances?

• There is LOTS of overlapping symptoms ​

• Focus on what is unique and different from 1 electrolyte toanother ​

• Focus on what is opposite between hypo and hyper

Chloride​ 95-105 mEq/L

• Involved in blood pressure and blood volume maintenance and pH balance ​

• Na+ and Cl- are friends and they move around together​ (also water) 

• Cl- and HCO3- are NOT friends —> opponents ​

  • since they are both anions, if one is low other will move to compensate (electrical neutrality) 

  • HCO3- = Basic substance that ↑pH​

  • Cl- moves from plasma into cells and HCO3- moves into plasma​

  • This shifting can be another buffer system to manage pH changes

  • alkolosis = vomiting (HCl lost = bicarb left behind), diuretics (excrete Na, K, Cl) 

  • acidosis = diarrhea —> bicarb in intestinal secretions

H+ and K+ relationship

• inverse relationship (both pos) 

• Acidosis (↑H⁺ in blood): H⁺ enters cells (to try buffer pH) → K⁺ leaves → hyperkalemia

• Alkalosis (↓H⁺ in blood): H⁺ leaves cells → K⁺ enters → hypokalemia

Magnesium​ 1.3-2.1 mEq/L

• Abundant Intracellular Cation (just like K+)​

• Involved in neuromuscular contractility (with Ca+, 2:1, more mag) = mag is for muscle RELAXATION, calcium = contraction

  • works w calcium for myocardial func + vascular tone 

• Neuromusclar junction (NMJ) --> ACh crosses synaptic cleft —> binds to receptor —> contraction, magnesium blocks ACh release (no muscle conc) 

Hypermagnesemia

Hypermagnesemia​

• Signs/Symptoms: Common Symptom:bradycardia, ↓ BP, weakness, ↓DTRs (deep tendon reflexes), lethargy —> coma ​

• Causes: Increased Intake – antacids or laxatives (mag stays in gut to draw water = diarrhea), too much IV, Decreased Excretion – renal disease​

Treatment:​

• Diuretics

Hypomagnesemia

​

• Signs/Symptoms: tachycardia & HTN,twitching, paraesthesia (tingling, numbness), hyperreflexia (positive Trousseaus’s & Chovstek’s signs), Irritability & confusion​

• Causes: Insufficient Intake –malnutrition,Celiac, Crohn’s, vomiting, diarrhea; Excess Excretion – diuretics, alcohol use disorder ​

Treatment: ​

• mag replacement 

Magnesium Replacement ​

• Oral Replacement (Asymptomatic) ​

  • MgOxide or MgSulfate (may cause diarrhea)​

• IV Replacement ​

  • Use MgSulfate —> slowly (arrhythmias) ​

  • Monitor for ↓Deep Tendon Reflexes ​

NOTE: Calcium and magnesium are also often friends —> If you have too little magnesium, you may also need to restore Calcium​

Calcium​ 9.0-10.5 mg/dL (4.5-5.3 mEq/L)

• Important role in muscle contraction, stabilizing cell membranes (neuromuscular excitability)​

• Absorption depends on Vit D​

• Friends with Magnesium, same reflected values (ex. calcium up, mag up)

• Calcium stables resting membrane potential --> too much wont be able to control depolarization (not going to open as much), less active potentials

  • INSIDE cell —> contracts

  • OUTSIDE cell —> less action potentials (too much)

Hypercalcemia

• High extracellular (blood) Ca²⁺ stabilizes voltage-gated sodium channels → fewer action potentials → muscles fire less → weakness

• Signs/Symptoms: decreased reflexes,N/V, bone pain/fractures,confusion/lethargy, weakness ​

• Causes: hyperparathyroidism, cancer,prolonged immobilization, Vit D overdose, acidosis, excess dietary intake​

• Treatment: ​

• Urinary excretion​

• Increase weight baring topromote bone mineralization​

Hypocalcemia

• Low extracellular Ca²⁺ → sodium channels less stabilized → more spontaneous action potential

• Signs/Symptoms: paresthesia around mouth, hyperreflexia, muscle cramps, Chvostek’s (facial twitch when tapping) and Trousseau’s sign (carpal spasm when inflating BP cuff for ~3 mins) ,seizures, confusion/lethargy ​

• Causes: thyroidectomy, vit D deficiency, kidney disease, alkalosis,alcoholism, laxative misuse,inadequate dietary intake​

• Treatment: ​

• Oral (Dietary supplement), or​

• IV if severe ​

Phosphate 3-4.5 mg/dL

• Important role in nerve and muscle function, RBC production, bones+teeth​

• ATP production relies on phosphate

• in bone calcium + phosphate bind together —> calcium phosphate

• Inverse relationship with Calcium

  • if both r high in blood —> can form crystals in soft tissues

  • PTH raises blood calcium (from bone), kidneys excrete phosphate

Hyperphosphatemia

• Signs/Symptoms: hypocalcemia,depression/anxiety, muscle cramps​

• Causes: kidney disease, chemo,laxative use, hypoparathyroidism,excess dietary intake​

• Treatment: ​

• Treat underlying cause​

• Treat hypocalcemia ​

• Administer phosphate binding agents​ (get excreted in stool)

A nurse is caring for a client who has chronic kidney failure andhypoparathyroidism. The client has been admitted for 5 days, andrecently stated to the nurse “I feel tingling around my mouth, and mylegs are aching!” Which electrolyte imbalance would the nursesuspect?​

A. Hypokalemia​

B. Hypocalcemia ​

C.Hypernatremia​

D. Hypercalcemia

B. 

The nurse is reviewing the intake chart for a new admission andnotes their most recent magnesium level is 3.6 (reference range=1.3-2.1 mEq/L). The nurse notes this patient’s assessment findings thatmay be may be associated with this result? Select all that apply. ​

A. BP 106/64 mmHg​

B. Muscle twitching​

C. Lethargy​

D. HR 44 bpm​

E. Hyperreflexia

A C D

What is enteral nutrition? + indications ​

• Provides liquified foods into the GI tract via a tube ​​

Indications:​

• When the GI tract is functional, but oral intake is not meeting nutritional requirements ​

• May be required for pts with swallowing disorders, burns, trauma,organ failure, severe malnutrition​

Gastrointestinal Intubation​

Uses​

• Deliver enteral nutrition, or ​

• Remove gastric contents with suction​​

Different Types of Tubes​

• OG, NG & G-Tube (PEG) —> end in your stomach​

• SBFT & J-Tube —> aka post pyloric feeding tubes —> end somewhere in your intestine

Orogastric Tube (OG)

• Inserted orally and tip is in the stomach​

• Large diameter ​

• ER or ICU (unconscious clients)

• Suction

• end in stomach 

Nasogastric Tube (NG)

• Inserted nasally and tip is in the stomach​

• Moderate diameter (suction) to small diameter (feed)

• Suction + ​Enteral Feeding ​

• Short Term < 4 – 6 weeks

• in stomach

Gastrostomy Tube (G-Tube)

• Surgically inserted - tube passes through the abdominal wall into the stomach ​

• Large diameter

• Feeding ​

  • Long-Term

  • ends in stomach

Small Bowel Feeding Tube (SBFT)​ / nasoduodenal tube

• Inserted through nose and tip is in the duodenum ​

• Small diameter ​

• Feeding ​

• Medium Term < 4 – 6 weeks

• ends in intestines 

  • bypass stomach, reduce risk of aspiration

  • NEVER ASPIRATE + NEVER check residuals (doesn’t store food/fluid like stomach, intestinal wall more delicate)

  • feeding tolerance checked —> abdo distention, cramping, N/V

Jejunostomy Tube (J-Tube)

• surgical procedure —> tube passes through the abdominal wall into the jejunum of the small intestine ​

• Larger diameter ​

• feeding ​

• Long-Term

• NEVER ASPIRATE + CHECK RESIDUALS 

• bypass stomach = reduce risk of aspiration

GI Intubation Insertion: General Steps ​

• Assess Safety – are there contraindications?​

• Review Order ​

• Collect Supplies ​

• Prepare the Patient and the Environment ​

• Insert per agency protocol ​

• Check placement before use– method to verify placement is dependent on agency. Likely to involve x-ray, other methods include aspirating for gastric contents and measuring pH, or may involve air instillment and auscultation

  • Air instillment and auscultation + aspirating are often prone to failure --> xray important

  • you may not be the one inserting it but before using it, make sure where it is supposed to be

Enteral Feeding​ types 

• Multiple types of enteral feeding methods, dependent on client, needs, setting​

• All as prescribed by provider, dietician ​

• Bolus: resembles normal meal patterns, formula is administered of 30-60 minute period every 3-6 hours​

• Continuous: Feeding administered continuously over 24hours via infusion pump​

• Cyclical: feeding is administered in daytime or night time hours over 8-16 hour period

Enteral Feeding Steps ​

• Confirmation order? Site? Length?​

• Assess bowel sounds prior to feeds ​

• Flush prior to feeds for patency (typically 25-40mL)​

• Position the client appropriately to prevent aspiration—semi/high fowler’s/reverse trendelenberg. Min 30-45 degree ​

  • during feed + 30 mins after 

• Aspirate residual volume and return contents to stomach PER ORDER

  • ​to ensure things move appropriately + pt tolerating well —> lots of volume = gastric paresis (could be) 

• Warm feeds to room temp to prevent diarrhea or cramps ​

• Change tubing every 24 hours ​

• Hang 4 hours of feed at a time to prevent bacterial growth​

• Flush after feeds​

• Administer other flush per agency policy/pt orders ​

free water flushes

Extra amounts of sterile or tap water (as ordered) given through a feeding tube in addition to formula.

• Maintain hydration — some formulas don’t provide enough free water.

• Prevent clogging of the feeding tube.

• Help meet fluid requirements, especially when feedings are concentrated or cyclical.

Enteral Feeding Considerations​

• Provide appropriate and routine oral care! ​

  • Often overlooked when patient is not taking intake by mouth ​

  • Need to clean, moisten, maintain oral health​

• When initiating first enteral feeds, ensure routine monitoring of fluid balance (daily weights, I/O q hourly with first admins *think what would happen if it went many hours without checking and something was wrong!) until reached stability​

  • pt could b confused = pull out tube 

  • aspirate, unable to tolerate

• Changes to respiratory status when administering enteral feeds may = aspiration – STOP feed and assess!

  • difficulty breathing, gurgling sounds, abnormal lung sounds

Enteral Medication Admin​

• Use liquid medications where possible ​

• Crush tabs thoroughly​

• Empty capsules ​(CANNOT b crushed) 

• Do not administer any coated medications ​(DONT CRUSH!)

  • e.g. enteric coated --> meant to break down in small intestine not stomach

• Dissolve meds in water ​

• Flush prior to and after medication administration​

• Consideration – you do not want to fluid overload the client.Ensure you are accurately calculating all the flushes you are giving. If you give medication flushes, subtract from routine flushes

Gastrointestinal Suctioning​

• Decompress stomach by removing fluids or gas to promote abdominal comfort​

  • Bowel obstruction --> stomach is still making gastric juices + gas (can be uncomfortable) --> suction out

• Decrease risk of aspiration​

• Suction settings between 0-80 mmHg, typical 40-60 mmHg ​

Suction​ Types

• Continuous/Straight (Immediate removal of contents)​

  • emergency (can be dangerous) 

  • risk of injury to mucosa 

• Low-Intermittent (Prolonged decompression) ​

  • starts and stops

​

Gastro Tubes: Nursing Assessments​ NG & SBFT (sunction)

• Location —> Has it moved? What number is it at? Does itneed reinforcement? ​

• Patency —> Is it draining? – if not; flush to clear blockage.​

  • may be on the mucosa = reposition patient 

• Drainage —> volume, colour? --> 125 mL/hr would be !!!​

  • 125 ml/hr = can impact intravascular fluid 

• +/- Feeds, Flushes & Residuals ​(if they r ordered) 

• Mucosa and skin Integrity?

Gastro Tubes: Nursing Assessments​ G-Tube & J-Tube (sunction)

• Patency ​

• Feeds, Flushes & Residuals ​(check for)

• Skin Integrity? Daily site dressing change? – goal: keep stoma dry!

Aspiration Pneumonia

• Fluid + food into alveoli not allowing gas exchange, carries bacteria

• Fever and increasing WBC​

• SOB, increased RR, SpO2​

• Confusion ​

• Abnormal breath sounds ​—> diminished or crackles

• can lead to sepsis

• Prevention: Keep HOB elevated> 30 for feeds and following

GI Related

• Nausea, Diarrhea, Gas​

  • Change feed type? More fiber? ​

  • Dietitian --> to change feed

• Constipation ​

  • Bowel protocol Initiation?​ —> laxatives, fluids, stool softener etc. (per provider order)

• Dumping Syndrome​

  • food rapidly goes into small intestine without digestion (in stomach)

  • Fullness/Distention, N&D​

  • FVD (dry vascularly) —> tachycardic, hypotensive

    • Lot of hypertonic solution/food entering + undigested glucose

    • causes fluid to enter intestine —> takes away from fluid volume (veins)

    • flucuations in glucose

Blocked Tube

• Follow protocol​

• Blocked tubes may be flushed with pancreatic enzymes dissolved in sodium bicarbonate​

  • Need to consult provider for order ​

  • breaks down congealed feed

  • DO NOT PUSH if there is resistance (mucosa injury) —> flushing + repositioning insstead

• If tube blockage cannot be relieved —> change NG or SBFT to prevent nutrition disruption

  • try not to change surgical tubes

Removal: Nursing Considerations​

• Short – medium term --> e.g. nasal tubes (surgical usually not removed) 

• Consider clamping for a trial before removal ​

  • In case N, V and distention return​

• Flush with sterile water then remove ​

  • Never force or tug​

  • stomach contents still in tube can go into mouth/sinuses (if not flush)

• Support the client in oral care ​

Parenteral Nutrition (PN)​

• Administration of nutrients via the bloodstream when the GI tract is unusable​

• Indications: Non-functional GI tract, malabsorptionsyndrome, severe burns/trauma​

• Tailored to patient needs; composition changes withpatient condition​

• Components:​

  • Base Solutions: Dextrose and amino acids(protein)​

  • Additives: Electrolytes, vitamins, trace elements​

Methods of PN: Central Parenteral Nutrition (CPN):

• AKA total PN 

• Long-term support or high protein/energy needs​

• Administered via central venous catheter or PICC​

• Requires large central vein for rapid dilution​

  • very hypertonic solutions = rapid dil prevents vein irritation 

Methods of PN: Peripheral Parenteral Nutrition (PPN):

• Short-term support, lower protein/energy needs​

• Administered via peripheral catheter or vascular access device​

• Less hypertonic, risk of phlebitis (smaller veins) and fluid overload (PPN solutions need to be dilute = more fluid volume given)

Complications of Parenteral Nutrition​

• Catheter-related issues​

• Refeeding syndrome: occurs in patients during initial nutrient re-introduction following significant malnutrition​ = body taking nutrients from fat + muscle not used to glucose = insulin secretion starts

  • Characterized by electrolyte shifts (into cell) –predominantly: LOW phosphate, LOW potassium​ —> in blood

  • Fluid imbalances​ = fluid goes into cells = low blood volume, BP

• Blood glucose instability – close monitoring ​

Nursing Considerations: Parenteral Nutrition​

• Nursing considerations:​

• Closely monitor fluid balance until stable – daily weights, intake and output monitoring, assessment for S/S of hypo/hypervolemia ​

• Wean on and off – gradual rate increases ​

• Routine CBC and electrolyte monitoring – q 2 days until stable with changes to PN composition in response​

• Clients must tolerate 60% of caloric intake via GI tract to warrant discontinuation without =malnutrition​

  • ensure stability + meeting caloric needs

The nurse is developing a care plan for a client with a g-tube (PEG)tube. Which of the following are appropriate interventions for thenurse to include? Select all that apply. ​

​

A. Use a dry, sterile dressing at the PEG tube site ​

B. Add a maximum of 12 hours of feeding product at a time toprevent bacterial overgrowth ​

C. Maintain semi-fowler’s position for feedings​

D. Monitor weight, and intake and output​

E. Flush tube every 72 hours ​

A, C, D

B. = q 4 hrs

D = should be flushed before and after feds, taking meds etc.

A client with acute pancreatitis has a nasogastric tube in place for gastric decompression. The nurse notes that the client’s abdominal distention has increased and there is minimal output from the nasogastric tube. What is the most appropriate action for the nurseto take next?​

​

A. Increase the suction pressure​

B. Flush the NG tube​

C. Notify the provider​

D. Disconnect the suction​

B. Blockage of tube --> flush ​

• Don’t disconnect without provider order