IV Therapy, Fluid & Electrolytes
Movement of Body Fluid
Hypotonic solutions cause water to move into cells, leading to swelling.
Hypotonic Solutions
Used to treat or prevent cellular dehydration.
Pull fluid out of vessels and into cells, flooding cells.
Examples:
0.45% NS (Normal Saline, also denoted as 1/2 NS)
0.25% NS (1/4 NS)
Not for patients with cerebral edema or elevated ICP (Intracranial Pressure).
Osmolarity: < 270
Intravenous Therapy Procedure
Assess patient comfort.
Label the tubing, dressing, and solution clearly, indicating the date and time (Set Due).
Document preparation, procedure, and aftercare.
IV Therapy: Set Change Schedule
Venipuncture Site: Change every 72-96 hours.
IV Dressing:
Change when wet.
Adhere to agency policy.
Gauze: Change every 48-72 hours or as specified by agency policy.
Transparent Gauze: Change every 7 days or as specified by agency policy.
IV Tubing: Change every 96 hours.
IV Bag/Bottle: Change every 24 hours.
FLACC Scale
Used for pain assessment.
Components:
Face: No expression (0 points)
Legs: Normal position (0 points)
Activity: Lying quietly, moving normally (0 points)
Cry: No cry (awake/asleep) (0 points)
Consolability: Relaxed (0 points)
Interpretation:
0: No pain
1-3: Mild pain
4-6: Moderate pain
7-10: Severe pain
Blood Components
RBCs (Red Blood Cells), WBCs(White Blood Cells), platelets, plasma.
Red Cells in Additive Solution
Leukocyte Depleted
Store at 4°C (2-6°C).
Volume: supplied in 250-350 ml
Storage: 42 days , 1 - 6C
Infusion Time: Within 4 hours
Indications:
Severe Hemorrhage
Shock
Severe Anemia
Hypoxemia
Replaces RBC Mass Emergencies
Assessments:
Pain Rating
Oxygen Saturation
Temperature
Pulse Rate
Respiratory Rate
Blood Pressure
Pulse Points
Temporal, Carotid, Femoral, Brachial, Radial, Popliteal, Posterior Tibial
Types of Transfusion
Autologous: Patient's own blood is collected and reinfused later.
Reduces the risk of disease transmission and potential transfusion complications.
Not an option for patients with leukemia or bacteremia.
Homologous / Allogeneic: Blood is donated by another person.
Designated Donor: Patient selects their own compatible donors.
IV Tubing Setup
Primary IV bag, injection port, sterile spike, drip chamber, back check valve, primary IV tubing, slider clamp, roller clamp (regulates rate), Luer lock.
Secondary IV bag, injection port, secondary tubing, IV pole, extension tubing, clamp, cannula.
Intravenous Therapy Procedure
Disinfect the area with alcohol prep pads.
Pulse Rate
Radial Pulse: Palpable at 60-100 bpm.
Rhythm: Regular, strong, and firm.
Grading Scale for Pulses:
4+ = Strong and bounding
3+ = Full pulse, increased
2+ = Normal, easily palpable
0 = Absent, not palpable
Factors Increasing Pulse Rate: Exercise, emotions, pain, increased body temperature, medications (stimulants).
Blood Products
Whole Blood, Packed Red Blood Cells (PRBCs), Platelet Transfusions, Fresh Frozen Plasma.
Acceptable Ranges of Heart Rate
Infant: 120-160 bpm
Toddler: 90-140 bpm
Preschooler: 80-110 bpm
School Age: 75-100 bpm
Adolescent: 60-90 bpm (other sources: 60-100 bpm)
Adult: 60-100 bpm
MAP (Mean Arterial Pressure)
Average pressure in the arteries during one cardiac cycle.
Reflects overall blood flow and organ perfusion, especially in the brain, kidneys, and heart.
Calculation: , where SBP is systolic blood pressure and DBP is diastolic blood pressure.
FLACC Scale Repeat
*Face: No Expression (0 points)
*Legs: Normal Position (0 points)
*Activity: Lying Quietly, Movement (0 points)
*Cry: No Cry (awake/asleep) (0 points)
*Consolability: Relaxed (0 points)
*Interpretation:
0: No Pain
1-3: Mild Pain
4-6: Moderate Pain
7- 10: Severe Pain
Hypertonic and Hypotonic Solutions
Hypertonic Solution:
High Osmolarity than the Blood (Higher concentration of solutes in fluids)
Osmosis will cause water to leave the Intracellular space (cell shrinks)
Expands extracellular space
Example: 3% Saline, Dextrose 10% in water, Dextrose 5% in 0.9% Saline Solution
Hypotonic Solution:
Lower osmolarity than the blood (lower concentration of solutes in fluid)
Osmosis will cause water to move from extracellular space to the intracellular space (cell swells)
Ex: 0.45% Saline, 0.225% Saline, 0.33% Saline, D5W (starts as Isotonic, ends as Hypotonic)
Body Temperature Location
0-2 years
3-10 years
Oral 35.5C- 37.5C
Rectal MOST AC 36.6C- 38.oc
Axillary SAFEST/ L 34.7CA3Rc 35.9C- 37.8C/Axillary SAFEST/ L 34.7CA3Rc 35.9C- 37.8C
Ear 36.4C- 38.oc
Core 36.1C-37.1C
IV Catheter Sizes and Flow Rates
Orange: 14G, 240 mL/min, 1 Liter in ~4 minutes
Gray: 16G, 180 mL/min, 1 Liter in ~5.5 minutes
Green: 18G, 90 mL/min, 1 Liter in ~11 minutes
Pink: 20G, 60 mL/min, 1 Liter in ~17 minutes
Yellow: 24G, 36 mL/min, 1 Liter in ~28 minutes
Blue: 22G, 20 mL/min, 1 Liter in ~50 minutes
Purple: 26G, 13 mL/min, 1 Liter in ~77 minutes
Understanding Blood Pressure Readings
Normal: Systolic < 120 and Diastolic < 80
Elevated Blood Pressure: Systolic 120-129 and Diastolic < 80
High Blood Pressure (Hypertension) Stage 1: Systolic 130-139 or Diastolic 80-89
High Blood Pressure (Hypertension) Stage 2: Systolic 140 or higher or Diastolic 90 or higher
Hypertensive Crisis: Higher than 180 and/or Higher than 120 (consult your doctor immediately)
ABO Blood Group Antigens
Type A: A-antigen, Anti-B antibodies
Type B: B-antigen, Anti-A antibodies
Type AB: A and B antigens, No antibodies
Type O: No antigens, Anti-A and Anti-B antibodies
Electrolytes & IV Therapy Fluids
Ions, Charged Molecules Burn Injury
*Infant: 120-160 bpm
*Toddler: 90-140 bpm
*Preschooler: 80-110 bpm
Fluid Output
Skin (Insensible and Sweat): 500-600 mL
Insensible Lungs: 400 mL
Gastrointestinal: 100-200 mL
Urine: 1200-1500 mL
Total: 2200-2500 mL
Fluid Input
Body Water Distribution
Total Body Water: 60% of body weight
Intracellular Fluid (ICF): 2/3 of total body water (25-28 Liters)
Extracellular Fluid (ECF): 1/3 of total body water (14-15 Liters)
Intravascular Fluid (Plasma): 20% of ECF (3 Liters) - Fluid in circulation
Interstitial Fluid: 80% of ECF (11 Liters) - Fluid in circulation
Movement of water occurs passively in response to osmotic gradients.
Cryoprecipitated AHF LR
Volume: 5 20ml/unit; 1 unit/ 10kg body weight
Infusion Time: Infuse Immediately for 15-30mins
Highly Concentrated form of Fibrinogen Prepared from FFP
Storage: up to 1 year; -18C or colder
Indications:
*Hemophilia
Fresh Frozen Plasma (FFP)
Replaces Fibrinogen Von Willpq / 1 ok's Diseases
*Volume: 300 — 550ml, Infusion Time: within 4 hours
*Storage — 35 days; 1 -6C
*Indications: Massive Hemorrhage Trauma, CS Delivery
Routine Clinical Approach in to pain assessment and management "ABCDE"
*A - ASK "REGULAR / SYSTEMATIC" > > > Quality, Location, Severity and Timing
*B - BELIEVE - the patient and family when pain is reported
*C- CHOOSE - PAIN CONTROL - Pain Meds / Complimentary Therapies
*D - DELIVER - the Intervention properly and timely
*E - EMPOWER - the Patient and the Family
Movement of Body Fluid
Hypertonic solutions cause water to move out of cells, leading to shrinkage. Used to decrease Intercellular volume and Increase vascular volume Pulls fluid out of cells and into vessel to expand intravascular space
Can be used to treat hyponatremia, to eeli Shrink
Conditions
*Decrease cerebral edema or to treat hight: D50, 3% ns, albumin ICP
*Osmolarity = > 300
Fresh Frozen Plasma (FFP)
Volume: 200-250 ml
Infusion time: Thawed first prior to Infusion within 2 hours; 15-30 minutes infusion time
Storage: Up to 1 year; -18C
Indications: Disseminated Intravascular Coagulation Thrombotic Thrombocytopenic Purpura (TTP)
Set Due in IV Therapy
*CHANGE VENIPUNCTURE SITE • Every 72hours to 96hours
*CHANGE IV DRESSING • When wet: As Needed or as specified by the Agency Policy
*Gauze: 48 — 72 hours or as specified by the Agency Policy
*Transparent Gauze: 7 Days or as specified by the Agency Policy
-CHANGE IV TUBINGS • Every 96 Hours
*CHANGE IV BAG / BOTTLE • Every 24 Hours
IV Fluids Color
D5 IRS PINK
D5 0.3 NaCl LIGHT BLUE
Pulse Oximetry
Noninvasive test that registers the oxygen saturation of a patient's hemoglobin.
The capillary oxygen saturation (Sa02) is recorded as a percentage.
The normal value is 95% to 100%.
Key Measurements for Oxygen Saturation and Pulse Rates
*Pulse Rate is measured by the number of contractionsof the heart per minute.
*The PI is useful for quickly evaluating the appropriateness of a monitoring site for pulse oximetry
Blood Pressure
*The difference between the systolic and diastolic pressures is alled the pulse pressure.
Pulse Pressure (PP)
<25mmHg: Narrow PP - Shock, Heart Failure
>60mmHg: Wide PP - Stiffiness of the artery -Risk for stroke
Normal range: between 40 and 60 mm Hg
*Importance: Measuring risk pressure disease espically for older Adults.
Contraindications of Blood Pressure Measurement
*Verify Doctors Order
*Explain Procedure and Gather Consent
*Assess for Contraindications
*Edematous Extremity
*Arm Weak, Traumatize or Paralyzed
*Same side as a Mastectomy
*Arteriovenous Fistula or Shunt for Dialysis
*Skin Area that is Infected
Blood Transfusion Procedure
Transfusion Therapy or Blood replacement is the IV Administration of whole blood, its components or a plasma derived products for therapeutic purposes
PURPOSE: Restore intravascular volume
Restore the oxygen-carrying capacity of blood (Hgb)
Provide clotting factors
For patients with hypovolemic shock (loss of blood volume)
Types of Infusion Pumps
*ALTERATIONS IN BREATHING PATTERNS TACHYPNEA, BRADYPNEA AND HYPERPNEA
Newborn: 30 - 60cpm
Infant: (6mos) 30 - 50cpm
Toddler: (2y/o) 25 - 32cpm
*Child: 20 - 30 cpm
*Adolescent: 16 - 20cpm (12 - 20cpm other sources)
Breathing Patterns
*HYPERVENTELATION - RR Increased, Inc. in Rate Depth, Hypocarbia
*HYPOVENTELATION - RR is abnornamally LOW, depth is depressed, Hypercarbia
*APNEA - Persistent ceassation in Respiratory Arrest / respirations are cease for several seconds
*ORTHOPNEA - Difficulty of breathing while lying flat
*KUSSMAULS - "Saw tooth Pattern" Deep, Labored, Rapid Breathing
*CHEYNE-STOKES - Cyclic Pattern - Shallow --> Deep --> Apnea
*BIOTS - Irregular breathing with periods of apnea (brain Injury)
ACCEPTABLE RANGES IN RESPIRATORY RATE (sources may vary) Potter and perry)
*Verify Doctors order, Secure Informed Consent
*Two RN Check, Two Nurses must verify patient identify and blood products
*Adult: 12 - 20 cpm
Blood Transfusion Procedure
*Assure patency of IV line
*Hang PNSS Bottle/ Bag
*Spike PNSS bag, Prime tubing, Fill the Blood Filter
*Close PNSS roller clamp
*Spike Blood Bag
*Open Blood roller clamp and prime tubings
*Connect IV tubing to Patients IV Access A-C-E-C-l
Types of Pain
Acute (Transient Pain): A TEMPORARY ACHE
Chronic (Persistent): PAIN >3months, Days
*Episodic pain:
*Cancer pain: ASSOC. to the tumor,
*Idiopathic pain: UNKNOWN. comes from unidentifiable cause - psychological or physical Ex: Arthritis
IV Catheter Sizes and Flow Rates
Orange 14G 240mL/min:Trauma, Surgery, Rapid Infusion
Gray 16G 180mL/min:Trauma, Surgery, Rapid Infusion, Blood transfusions
Green: 18G 90mL/min: 0.9% NORMAL SALINE
*Pink: 20G 60mL/min:MED
*Blue:22G 36mL/min:
*Yellow:24G 20mL/min:
*Purple:26G 13 mL/min:
ABO Blood Groups - Important Notes
*Type A A - antigen
Receive From: A O Donates to: A, AB
*RECEIVE FROM: B, o DONATE TO: B, AB
*RECEIVE FROM: ALL DONATE TO: AB
*RECEIVE FROM O DONATE TO: ALL
Fluid Movement Illustration
*H20 Outsido/Inside
*EQUAL concentration/ Cell remain constant
*LOWER concentration Water move into the cell/ Cell expand and lyse
*HIGHER concentration/ Water move out from cell causing shrinkage
Blood Transfusion Procedure
Transfusion Therapy or Blood replacement is the IV Administration of whole blood, its components or a plasma derived products for therapeutic purposes
*PURPOSE:
*Restore intravascular volume
*Restore the oxygen-carrying capacity of blood (Hgb)
*Provide clotting factors
*For patients with hypovolemic shock (loss of blood volume)
Blood Transfusion Reaction - Actions
*STOP TRANFUSION
*CHANGE IV TUBING DOWN TO THE IV SITE
*KEEP LINE OPEN WITH PNN
*CHECK VITAL SIGNS
*NOTIFY PHYSICIAN
*STAY WITH THE PATIENT, MONITOR VS EVERY 5 MINUTES
*PREPARE EMERGENCY MEDS
*OBTAIN URINE SPECIMEN AND OTHER SPECIMEN AS PRESCRIBED
*RETURNS, BLOOD BAG, TUBING, ATTACHED LABELS AND
*TRANSFUSION RECORD TO THE BLOOD BANK
*DOCUMENT
Diffusion: Movement of solutes from high to low concentration.
*Solutes, gases, small molecules
*No energy needed
Dye Molecules Water Molecules High Movement to Diffused evenly concentration low concentration (Equilibrium)
Diffusion
Blood Transfusion Monitoring and Completion
Set Infusion pump to deliver blood at no more than 2ml per minute for the first 15 minutes, then regulate according to Doctors order
*Monitor Patient for adverse reaction
*Measure vital signs when infusion is complete
*Disconnect blood tubing
*Flush IV line and evaluate patient's response to transfusion
*Discard tubing and blood bag
*Flush IV as needed
Common Intravenous Sites
*Basilic veinCephalic Median vein cubital vein Median vein Cephalic of forearm veinBasilic vein Radial Superficial dorsal veins vein Dorsal Cephalic venous arch vein Basilic vein. Inner arm. B, Dorsal surface of hand
Types of Pain Scales:
Numerical
No Pain (0) to Severe Pain (10)
Descriptive
No pain, Mild Pain, Moderate Pain, Severe Pain to Unbearable Pain
Visual analog
Clients designate a point on the scale corresponding to their perception of the pain's severity at the time of assessment.
NO pain ------>Unbearable Pain
Common Numerical Pain Scale Descriptors
*0: No Pain
*2: Hurts a Bit
*4: Hurts a little more
*6- Hurts even More
10 Hurts Whole Lot
Nonverbal Indicators of Pain
*Moaning
*Crying
*Irritability
*Restlessness
*Grimacing or frowning
*Inability to sleep
*Rigid posture
*Increased blood pressure, hea respiratory rate
*Nausea
*Diaphoresis
Platelet Transfusions
Volume: 40–70 mL/unit; 1 unit/10 kg body weight
Infusion Time: 15 to 30 minutes; given rapidly upon receipt from the blood bank
Whole blood is centrifuged and the platelet rich plasma is separated
*Evaluated 1 hour and 18 to 24 hours after, an increase of 5000 to 10,000mm3 is expected.
Indications:
Thrombocytopenia
Platelets Dysfunctions
Body Temperature Balance & Measurement
*Body temperature reflects the balance between the heat produced and the heat lost from the body.
*There are two kinds of body temperature: core temperature and surface temperature
*Core temperature: temperature of deep tissues of the body, such as the abdominal cavity and pelvic Core Temperature, It remains relatively constant.
Adult Temp varies 97 to 99' f Common measurement sites are the mouth, rectum (unless contraindicated), axilla, and across the forehead (temporal artery site).
Body Temperature - Rectal vs. Axilla vs. Oral
*Rectal temperatures are usually 1 0 F (0.5 0 C) higher, and tympanic and axil temperatures about 1 0 F (0.5 0 C) lower than the normal oral temperature.
*RECTAL - Most Accurate (Core Temperature); Left side lying position, lubricated thermometer is inserted to the rectum TOWARD the umbilicus, adult - 1.5 inches; Infant 0.5 inches
*AXILLA - Safest but the least accurate Oral Under the tongue, one of the posterior pockets
Electrolytes: Sources and Functions
POTASSIUM - 3.5-5 mEq/L
*Source: Banana, A Potatoes. Fish - Sardines and Salmon
*Function Important in coductions of Nerves Impulses Promotion of proper skeletal, smooth and cardiac muscle activity
*SODIUM - 135 - 145 mEq/L
*Sources: Table salt, Processed Food, Canned Goods, Cheese, Fastfoods
Function Binibining Pilipinas (BBP)
Blood Pressure
Blood Volume
PH Balance
*CALCIUM: 9.0 - 10.5 mg/dL
*Dairy Products - Milk, Cheese and Yogurt, Vegetables - Brocolli, Bokchoy, Fish - Salmon and Sardines, Nuts and Almonds
*Function 3'Bs
Bones
Blood Clotting
Beat of my Heart
*MAGNESIUM - 1.3 - 2.1 mEq/LVegetables - Spinach, Peas, Legumes
Fruits - Banana, Avocado, Tofu and Brown rice
*Regulates:
Muscle - Protein Synthesis, Nerve function, Blood Sugar regulation
*Required Calcium and Vitamin D absoption/ABSORPTION
PHOSPHATE 3 - 4.5 mg/dL
*Seeds
*Beans & Nuts and Almonds
*Bone and Teeth Formation, Regulate Calcium, Necessary for ATP Production
CHLORIDE: 98 - 106 mEq/L: same sodium
Types of Fever
*FEVER CONTINOUS S.I.R.R.
*Sustained: A constant body temperature continuously above 38 0C (100.40F) that fluctuation TYPHOID FEVER
*Intermittent: Fever spikes interspersed with usual temperature levels (Temperatur to acceptable value at least once in 24 hours.
*ON AND OFF (within 24 hours) Dengue
*Remittent: Fever spikes and falls without a return to acceptable temperature levels
*Relapsing: Periods of febrile episodes and periods with acceptable temperature (Febrile episodes and periods of normothermia are often longer than 24 hours.) MALARIA •
Respiratory Rate Basics
*Respiration is a mechanism the body uses to exchange gases between the atm the blood and between the blood and the cells.
*Respiratory rates may vary with age.
*The normal adult respiratory rate is 12 to 20 breaths per minute. Normal
*Eupnea; Eu = Good
Normal Rate: (12 — 20cpm) Normal depth (Not too shallow, Not too Deep, No adventitious breath sounds)
Respiratory Rate - Medical Definitions
*Fast breathing > 20 cpm Tachypnea
*Slow breathing < 12 cpm for adults Bradypnea
*Faster than 20cpm and with deep breathing ,labored Hyperpnea
Physiology of Blood Pressure
Blood pressure is the force on the walls of an artery exerted by the pulsating blood under pressure from the heart.
The heart's contraction forces blood under high pressure into the aorta; the peak of maximum pressure when ejection occurs is the systolic pressure; the blood remaining in the arteries when the ventricles relax exerts a force known as the diastolic pressure.
The difference between the systolic and diastolic pressures is called the pulse pressure.
Blood Pressure - Management "ABCDE"
*A - ASK "REGULAR / SYSTEMATIC" > > > Quality, Location, Severity and Timing
*B - BELIEVE - the patient and family when pain is reported
*C- CHOOSE - PAIN CONTROL - Pain Meds / Complimentary Therapies
*D - DELIVER - the Intervention properly and timely
*E - EMPOWER - the Patient and the Family
Osmosis What it is: Movement of water only through a semipermeable membrane.
How it works
Water moves from an area of low solute concentration to an area of high sol concentration to balance things out.
Example in the body In the kidneys, water moves from the filtrate in the tubules back into the
depending on solute concentrations. Water-specific Needs a semipermeable membrane Driven by solute concentration difference
Blood Pressure - Time of day/Factors/How to take reading properly
*BP typically lowest in the morning, gradually increase during the day, peaks in the later afternoon and evening. - Factors that affects BP: Smoking, Activity (Exercise), Body Weight - 30 Minutes rest for Patient - Exercise and Smoke - Patient will assume resting position either lying in bed or setting (flat on the floor feet), rest for 5minutes - Korotkoff Sound, 1st Phase -> Systolic and 5th phase -> Diastolic
IV Drip Sizes
Macrodrip
E-40
60 m(I)crodrip
10-20 gtt/mL
80
100
Macrodrops commonly have drop factors of 10,
12, 15, or 20 drops/mL
Microdrip
60 gtt/mL The drop factor for microdrip sets is always 60 drops/mL
Physical Assessment (IPPA) - Fluid and Electrolyes
*Nursing History: Level of Conciousness Dietary Intake Life style and environment Medications Signs and Symptoms
*Medical History: Surgery, Gastrointestinal Output, Acute illness or Trauma, Respiratory Disorders, Burn Illness, Cancer, Heart failure, Renal Disease
*Daily weight, Intake and Output Measurements
Weight = Best Indicator of Fluid retention or Fluid Loss
*cc = l g Iml = lg 1000cc = Ikg or 2.2 lbs 1 Liter = 1 Kilograms or 2.2lbs
Fluids, Electrolytes & Homeostasis: Key Terms
*Electrolytes — Ions found in body fluids; help to conduct electricity, energy and control body fluids
Homeostasis — balance / equilibrium; maintain self regulating process
"KU-SO- CAL-MA-PO CHAAAAR"
*POTASSIUM 3.5 - 5 mEq/L
*SODIUM - 135 - 145 mEq/L
*CALCIUM - 9.0 — 10.5 mg/dL
*MAGNESIUM 1.3 - 2.1mEq/L
*PHOSPHATE - 3.0 — 4.5 mg/dL
*CHLORIDE - 98 - 106 mEq/L
Stages of Hypothermia by Celsius and Fahrenheit
*MILD: 32-35/ C (90-95/ F)
*Moderate: 28-32/ C (82-90/ F)
*Severe: less then 28 C (less then 82/ F)
Isotonic Fluids
ISO = EQUAL
*TONIC = Strength
Ability of how Osmolarity — Amount of solutes within a specific fluid /Volume High Osmolarity = High Solutes (Less water)
Low Osmolarity = Low Solutes (More water)
ISOTONIC — Same osmolarity as the blood (same concentration of solutes) - equal transfer of water
NOT affecting the cell - It expands extracellular volume (plasma) - Why give Isotonic Solution? Answer: Fluid Loss in extracellular space - Vomiting, Diarrhea, Burns, Hypovolemic Shock