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🔹 Rehydration Overview

• Definition: Rehydration restores lost water to the body’s tissues and fluids.

• Causes of dehydration:

  • Medications

  • Inadequate fluid intake

  • Diarrhea

  • Other fluid-loss conditions

• Routes:

  • Oral (PO) – preferred if client is alert and able to swallow

  • Intravenous (IV) – if oral route is contraindicated or insufficient

🔹 Oral Rehydration

• Appropriate for all ages, provided:

  • Renal function is adequate

  • Client can safely swallow

• Options:

  • Water

  • Sports drinks (to replace electrolytes)

• Nursing care:

  • Accurately document intake and output (I&O):

    • Every hour or per facility protocol

  • Monitor urine specific gravity:

    • Low specific gravity may indicate overhydration (excessive dilution)

🔹 Pediatric Rehydration

• First-line for mild/moderate dehydration: oral rehydration

• Dosage:

  • 25 mL/kg over at least 2 hours

  • If tolerated, continue with total volume over 12 hours

• Mild dehydration: 50 mL/kg over 4 hours

• Moderate dehydration: 100 mL/kg

• Reintroduce age-appropriate diet once child is rehydrated and not vomiting

• Technique:

  • Assess swallowing ability

  • Administer 5 mL every 5–10 min, increase as tolerated

  • Use syringe, slowly deliver toward the side of mouth

  • Prevent choking/aspiration

🔹 Older Adult Rehydration

• Risk factors:

  • Diminished thirst sensation

  • Lower total body fluid volume

  • Decreased kidney function

  • Comorbidities (e.g., heart failure)

  • Medications (diuretics, laxatives)

• Nursing priorities:

  • Encourage frequent fluid intake

  • Involve staff awareness of hydration needs

  • Increase fluids during:

    • Fever, diarrhea, vomiting

    • Heat or physical activity

  • Be cautious with fluid restrictions for cardiac or renal failure

🔹 Intravenous (IV) Rehydration

• Used when:

  • Oral route is not tolerated or insufficient

• Benefits:

  • Immediate fluid delivery into bloodstream

  • Corrects electrolyte/fluid imbalances

• Nursing responsibilities:

  • Select proper vascular access

  • Monitor:

    • IV site, tubing, and dressing

    • Flow rate and solution type

    • Skin integrity

    • Lab results (electrolytes, renal function)

    • Intake and output

🔹 IV Access & Tourniquet Use

• Tourniquet:

  • Applied 5–10 cm above site

  • Check distal pulse to avoid excessive pressure

• Avoid tourniquets in:

  • High bleeding risk

  • Poor circulation

  • Fragile skin

• Alternatives:

  • Use BP cuff at 30 mmHg

  • Warm compress

  • Fist pumping

  • Gravity-dependent arm position

🔹 IV Site Selection

• Adults: Distal forearm (non-dominant hand preferred)

• Avoid:

  • Recently used IV sites

  • Joints (antecubital space)

  • Areas with trauma, pain, or radiation

  • Extremities with:

    • Lymphedema

    • AV fistula

    • Stroke involvement

• Pediatrics:

  • Hands or feet

  • Scalp (infants)

• Emergencies: Intraosseous (IO) access:

  • Sternum, tibia, femur, humerus

• Do not use:

  • Tortuous (crooked), hard, painful veins

🔹 IV Solution Types

🔸 Crystalloid Solutions

• Contain electrolytes and/or dextrose

• Can cross cell membranes

• Classified by tonicity:

  • Hypotonic (<250 mOsm/L)

  • Isotonic (250–375 mOsm/L)

  • Hypertonic (>375 mOsm/L)

🔹 Crystalloid Solution Comparison

🔸 Colloidal Solutions

• Contain large molecules that stay in intravascular space

• Increase osmotic pressure → pulls fluid into bloodstream

• Types:

  • Natural: Albumin

  • Synthetic: Dextran, Hetastarch

• Expensive and used in critical volume restoration

🔹 Colloidal Solution Comparison

• Nursing actions before and during colloid infusion:

  • Use 18G or central IV line

  • Obtain allergy history

  • Monitor for hypervolemia:

    • HTN, edema, JVD, crackles, dyspnea

🔹 IV Flow Rate Basics

• Definition: The rate at which IV fluids are infused.

• Determined by:

  • Client’s clinical presentation

  • Need for replacement fluids (e.g., dehydration, blood loss)

• Nurses calculate:

  • Flow rate (mL/hr)

  • Infusion time

  • Total volume

  • Based on the provider's prescription

• Methods of administration:

  • Volume-control pump:

    • Electronic pump that regulates precise infusion rate

  • Gravity:

    • Nurse must manually regulate the rate using clamp and drip chamber

🔹 Selecting and Maintaining IV Tubing

• Types of tubing:

  • Primary tubing:

    • Main line for delivering IV fluids

  • Secondary tubing:

    • For IV piggyback medications

    • Connects to primary tubing via needleless adapter

• Specialized tubing used for:

  • Blood

  • Lipids

  • Nitroglycerin

  • Total Parenteral Nutrition (TPN)

🔹 Gravity IV Tubing

• Requires nurse to:

  • Be skilled in calculating dosage

  • Manually set and adjust the flow rate

• Accuracy is crucial to avoid over/under-infusion

🔹 Preventing Infection in IV Therapy

• Major risk of IV therapy: infection

• Aseptic technique is essential for:

  • Manipulating IV bag, tubing, and connectors

  • Caring for IV insertion site

• Needleless connector disinfection:

  • Clean before every use

  • Disinfectants may include:

    • Chlorhexidine

    • 70% alcohol

    • Povidone–iodine

  • Some facilities use passive disinfection caps:

    • Contain disinfectant-saturated sponge

    • Provide continuous disinfection between uses

  • Allow drying time after cleaning before connecting tubing

🔹 Central Venous Access Devices (CVADs)

• Inserted into large veins:

  • Internal jugular, subclavian, femoral, brachiocephalic

• Risk of CLABSI (Central Line-Associated Bloodstream Infection) increases with dwell time

• Dressing care:

  • Use chlorhexidine gluconate dressing (unless contraindicated)

  • Change at least every 7 days or when dressing is soiled or loose

• Hub disinfection ("Scrub the hub"):

  • Clean injection port with alcohol-based CHG before each access

  • Option: Sterile passive disinfection caps:

    • Contain 70% isopropyl alcohol or chlorhexidine

    • Applied to hub and replaced with each access

🔹 IV Tubing and Solution Bag Changes

• Follow facility policy for tubing changes

• Infusion Nurses Society (INS) Standards:

  • Continuous infusions: Change tubing every 96 hours

  • Intermittent infusions: Change tubing every 24 hours

• Immediate change required if:

  • Contamination is suspected

  • Closed system integrity is compromised

• Blood and lipid tubing:

  • Lipids: Change every 12 hours and with each container

  • Blood products:

    • Change after every unit or every 4 hours

🔹 Peripheral IV Catheter Site Care

• Stabilization of catheter is critical to:

  • Prevent complications

  • Maintain patency and dwell time

• Complications of poor stabilization:

  • Cannula movement

  • Phlebitis

  • Loss of access

  • Infection

• Stabilization products:

  • Clear plastic devices over IV site

  • Adhesive pads to secure catheter

  • Applied at time of insertion

• Nursing responsibilities:

  • Regularly inspect IV site

  • Ensure catheter is secure and intact

  • Remove catheter if:

    • Not used in the past 24 hours

    • No longer clinically indicated

🔹 Flow Rate Calculation Example

• Prescription: Infuse 3,000 mL of NS over 15 hours

• Formula:
  Flow Rate (mL/hr) = Total Volume (mL) ÷ Infusion Time (hr)

• Calculation:
  3,000 mL ÷ 15 hr = 200 mL/hr

• Answer: Set IV pump to 200 mL/hr

🔹 Converting or Discontinuing IV Access

• Once fluids or meds are done, nurse can:

  • Convert IV site to an IV lock (keeps access open)

  • Discontinue the IV if not needed

• Refer to:

  • Skill: Converting to Peripheral IV Lock

  • Skill: Discontinuing a Peripheral IV Catheter

Peripheral Intravenous Catheters

• Most commonly used IV therapy device.

• Inserted into extremities: hand and forearm are standard sites.

• Pediatric sites include: scalp and lower extremities.

• Available in various styles, lengths, and diameters—each suited to specific benefits and complications.

Types:

• Short peripheral IV catheter: Used for short-term duration.

• Midline catheter: Can remain in place for longer periods.

• Extended dwell catheter: Intermediate length between short peripheral and midline catheters.

Central Venous Access Devices (CVADs)

• IV devices placed into large veins.

• Tip sits in superior vena cava or inferior vena cava.

• Insertion: either percutaneous or surgically implanted.

Device Selection Based on:

• Solution characteristics:

  • Irritating fluids require midline catheter or CVAD.

• Length of therapy:

  • Short-term (<1 week): Short peripheral catheter.

  • Long-term: Midline catheter or CVAD.

• Client condition:

  • Unstable clients or those undergoing chemotherapy benefit from larger bore devices (e.g., CVAD).

Technology Aiding IV Insertion

• Transillumination: Light helps visualize veins; useful for children, obese clients, clients with dark skin.

• Ultrasound: Uses sound waves to locate veins.

Peripheral IV Catheter Details

• Single-lumen plastic catheter.

• Inserted into peripheral veins: hands, wrist, forearms, antecubital fossa.

• Less commonly: dorsal plexus of foot, scalp veins (neonates, infants).

• Sizes range from 14 to 24 gauge:

  • Larger number = smaller catheter.

• Catheter selection factors:

  • Client’s age, vein condition, fluid type.

  • Higher gauge/smaller diameter: Infants, elderly with fragile veins.

  • Lower gauge/larger diameter: Required for blood product administration to prevent RBC damage.

Categories of Central Venous Access Devices (CVADs)

Nontunneled CVADs

• Inserted into jugular, subclavian, or femoral veins.

Peripherally Inserted Central Catheters (PICCs)

• Inserted into upper extremity peripheral veins: median cubital, cephalic, basilic, brachial.

• Tip resides in superior or inferior vena cava.

• Can be antimicrobial-impregnated to reduce infection.

Subcutaneously Tunneled Cuffed Catheters

• Long-term use (can last years).

• Inserted through subcutaneous tunnel; exit site on lower thorax.

• Tip ends in superior vena cava.

• Synthetic cuff in subcutaneous tissue stabilizes catheter via scar tissue.

• Avoid sharp objects like scissors near catheter.

Implanted Vascular Access Port

• Surgically placed—usually in chest.

• Accessed with a noncoring needle.

• Port connects to silicone catheter placed into superior vena cava.

• Requires specialized training to access and flush.

Flushing Protocols for CVADs

• Use saline or low-concentration heparin as per facility policy.

• Prevents clot formation/occlusion.

Intravenous-Related Complications

Phlebitis

• Inflammation of tunica intima of the vein.

• Causes:

  • Cannula movement

  • Poor dressing

  • Infusion speed

  • Solution characteristics (pH, osmolarity, dextrose)

  • Length of therapy

  • Aseptic technique failure

  • Cannula too large for vein

• Symptoms:

  • Pain (at, around, proximal to site)

  • Swelling, erythema, fever

  • Palpable vein cord

Phlebitis Prevention:

• Maintain aseptic technique, hand hygiene.

• Select appropriate fluid and vein (use CVAD for vesicants).

• Use smallest appropriate cannula.

• Avoid flexion areas (use stabilization device if needed).

• Maintain correct infusion rate.

• Site monitoring:

  • At least q4h; q1–2h for vesicants, altered LOC, flexion site.

  • Hourly for pediatrics/neonates.

Phlebitis Treatment:

• Notify provider.

• Discontinue IV.

• Apply warm compress, elevate limb.

• Give analgesics if prescribed.

• Document findings and interventions, rate site, record new IV location.

Circulatory Overload

• Excess fluid infusion—too much, too fast.

• Causes:

  • Excessive IV fluids or blood

  • Poor monitoring

  • Cardiopulmonary or renal insufficiency

• Symptoms:

  • Tachycardia, HTN, JVD

  • Edema, weight gain

  • Crackles, cough, low O2 sat, cyanosis

Prevention:

• Monitor I&O, daily weight.

• Keep infusion at prescribed rate.

• Watch for symptoms, especially with NaCl solutions.

Treatment:

• Notify provider.

• Position in semi- or high Fowler.

• Administer oxygen.

• Maintain warmth.

• Document all assessments and interventions.

Infiltration and Extravasation

• Infiltration: nonvesicant fluid into tissue.

• Extravasation: vesicant fluid into tissue.

• Examples of vesicants: chemotherapy, D50, dopamine, phenytoin.

• Symptoms:

  • Cool skin, edema, pallor, delayed cap refill

  • Pain, burning, fluid leakage, sluggish flow

Prevention:

• Use correct vein and catheter gauge.

• Avoid small hand veins or flexion areas.

• Stabilize catheter.

• Assess patency before administration.

• Monitor site at least q4h; more often for vesicants.

Treatment:

• Stop infusion.

• Attempt aspiration (do not flush).

• Remove IV after aspiration.

• Mark affected area, elevate limb.

• Document: timing, site, med, technique, aspiration amount, S/S, provider notification.

Air Embolism

• Air enters bloodstream via IV tubing/CVAD.

• Causes:

  • Poorly primed tubing

  • Disconnected or loose connections

  • CVAD changes

• Symptoms:

  • Abrupt onset: dyspnea, wheezing, hypotension, tachycardia

  • Chest/shoulder pain

• Complications: shock, MI, neuro damage, death

Prevention:

• Prime all tubing.

• Secure all connections.

• Monitor for air bubbles.

• Change IV bag before it empties.

• Clamp CVAD during tubing change.

Treatment:

• Clamp line.

• Position head down, left side.

• Notify rapid response/code.

• Administer oxygen.

• Document full event.

Infection

• Caused by non-aseptic technique.

• Common, preventable HAI.

• Symptoms:

  • Redness, swelling, pain, purulence, fever

• Complications:

  • Thrombophlebitis, bloodstream infection

Prevention:

• Use aseptic technique

• Clean skin with soap/water before insertion

• Trim hair with clippers (do not shave)

• Maintain secure dressing

• Assess site regularly

Management:

• Notify provider.

• Culture site and cannula.

• Remove and clean site.

• Document findings, cultures, interventions, and reassessments.

Scope of Practice

• Defined by state Nurse Practice Act.

• May differ by state:

  • Some allow LPNs/LVNs to insert peripheral IVs and administer meds

• RNs can:

  • Insert and maintain peripheral IVs

  • Manage CVADs and PICCs (removal may require training)

RN Responsibilities:

• Know purpose of infusion, adverse effects, and solution characteristics

• Use judgment in assessing:

  • Labs, VS, skin, I&O, lung sounds

• Discuss plan with client; include preferences and prior IV experiences

• Ensure comfort and proper site selection

• Double-check fluids and meds

• Perform aseptic technique; change dressings per policy

Age-Related IV Therapy Considerations

Pediatrics:

• Consider developmental level and motor skills

• Secure limbs if needed

• Scalp veins used <18 months

• Avoid cultural issues with hair removal

• Avoid dorsum of hand if mobile

• Monitor site hourly

• Keep procedure separate from child’s main room

Older Adults:

• Fragile skin and veins, sclerotic changes

• Veins closer to skin surface

• Avoid tight tourniquet: use BP cuff or warm compress

• Pull skin taut, decrease insertion angle

Intake and Output (I&O)

Intake:

• Includes all oral, IV, tube feeds, irrigations

• Measured with calibrated tools

• Convert ounces to mL (1 oz = 30 mL)

Output:

• Includes: urine, stool, emesis, drains, NG

• Measured with graduated containers

• Diapers/briefs: 1g = 1mL

Documentation:

• Record at least every 8 hours or more often as needed

• Calculate balance: intake - output

  • Negative = fluid deficit

Pediatric Considerations:

• Water = 70–80% of body weight in infants

• Use daily weights and diaper weighing

• Accurately replace losses

Older Adult Considerations:

• Decreased fluid reserves and thirst

• Poor kidney function increases overload risk

• Close monitoring critical