Fluid and Electrolytes Flashcards

Composition of Bodily Fluids

• Blood (Intravascular): 4-5 liters. Blood is contained within the vessels and is crucial for transporting oxygen, nutrients, hormones, and waste products.

• Intracellular Fluid: 28 liters (fluid within cells). This fluid is essential for cell function and metabolism. It contains water, electrolytes, and proteins.

• Interstitial Fluid: 11 liters (fluid between blood and cells). This fluid surrounds cells, providing a medium for the exchange of nutrients and waste products between the blood and cells.

Fluid Imbalance

Volume Imbalances (Hypo- or Hypervolemia)

• Concentration/osmolality of the fluid is normal, but there is either too much or not enough fluid. These imbalances can result from conditions like dehydration, heart failure, or kidney disease.

• Hypovolemia (low volume): Treat with isotonic fluids for fluid replacement. Common causes include hemorrhage, severe vomiting or diarrhea, and inadequate fluid intake. Signs and symptoms include thirst, dry mucous membranes, tachycardia, and hypotension.

• Hypervolemia (increased volume): Usually treated with diuretics or dialysis (artificial kidneys) in severe cases. This can occur due to conditions like heart failure, kidney failure, or excessive sodium intake. Signs and symptoms include edema, weight gain, shortness of breath, and hypertension.

Osmolality Imbalances

• The amount of particles within a fluid contributes to the fluid's concentration. Osmolality is a measure of solute concentration per kilogram of solvent.

• The blood is either too concentrated or too dilute. These imbalances can affect cell function and cause neurological symptoms.

• High osmolality: Indicates a need for hypotonic fluid. This suggests the body is dehydrated or has too much sodium. Causes can include diabetes insipidus or excessive sweating.

• Low osmolality: Indicates a need for hypertonic fluid. This suggests the body has too much water or not enough sodium. Causes can include syndrome of inappropriate antidiuretic hormone (SIADH) or overhydration.

Movement of Fluid

Terms

• Hydrostatic Pressure: Force pressing outward against a surface. In the capillaries, this pressure pushes fluid out into the interstitial space.

• Osmotic Pressure: Inward pulling pressure towards a higher concentration. This pressure is primarily determined by the concentration of proteins (especially albumin) in the blood.

• Diffusion: Passive movement of particles from an area of high concentration to an area of low concentration. This process does not require energy.

• Active Transport: Using energy to move electrolytes across cell membranes. This is essential for maintaining electrolyte balance and cell function; for example, sodium-potassium pump.

Osmolality Measurements

• Blood Tests for Osmolality:

  • Normal value is between 280-300 mmol/kg.

  • This direct measurement is most accurate. Deviations from this range can indicate fluid or electrolyte imbalances.

• Urine Specific Gravity:

  • Normal is between 1.005 and 1.030.

  • Greater than 1.010 may indicate a hyperosmolar state (high osmolality), assuming normal kidney function. Kidney diseases can alter the urine specific gravity.

• Hematocrit and Hemoglobin:

  • Hematocrit is the percentage of red blood cells in plasma.

  • The higher the hematocrit, the higher the osmolality (assuming no other underlying reason for elevated hematocrits, such as chronic hypoxemia). Conditions like dehydration can increase hematocrit.

• Sodium:

  • "Where sodium goes, fluid follows."

  • If sodium is elevated \uparrow, osmolality is probably high \uparrow. Hypernatremia often leads to hyperosmolality.

  • If sodium is low \downarrow, then osmolality is probably low \downarrow. Hyponatremia often leads to hypoosmolality.

Fluid Movement Review

• Electrolytes move from one compartment to another by hydrostatic or osmotic pressure.

• Hydrostatic pressure pushes particles regardless of concentration. This pressure is crucial in capillary filtration.

• Osmotic pressure pulls particles from an area of larger concentration to an area of smaller concentration. This pressure helps maintain fluid balance between compartments.

Fluid Volume Status Assessments

• Weight: Daily weight measurements can indicate fluid retention or loss.

• Intake & Output: Monitoring fluid intake and urine output helps assess fluid balance.

• Blood Pressure & Pulse: Changes can indicate fluid volume deficits or excess.

• Orthostatic Vital Signs: These assess for volume depletion; a drop in BP and increase in HR when moving from lying to standing.

• Jugular Vein:

  • Too much fluid: jugular venous distention (JVD).

  • Too little fluid: collapse.

• Edema: Indicates fluid retention in the interstitial space.

• Lung Sounds: Crackles can indicate fluid overload.

• Skin Turgor Assessment: Decreased skin turgor can indicate dehydration.

• Mucus Membranes: Dryness can indicate dehydration.

Nursing Diagnoses

• Risk for impaired water-electrolyte balance

• Risk for impaired fluid volume balance

• Excessive fluid volume (FVO)

• Risk for excessive fluid volume

• Inadequate fluid volume (dehydration)

• Risk for inadequate fluid volume

• Ineffective tissue perfusion (blood loss)

• Decreased cardiac output (CHF)

• Lack of knowledge r/t…

Top 5 IV Fluids

• Normal Saline (NS) 0.9% NaCl:

  • Used to expand volume, dilute medications, and keep the vein open.

  • Commonly used for fluid resuscitation.

  • Isotonic (same osmolarity as body fluid). Safe for most patients but can cause fluid overload if administered too quickly or in large volumes.

• Lactated Ringers (LR):

  • Used for Na and volume replacement. Contains sodium, potassium, calcium, chloride, and lactate in concentrations similar to those of plasma.

  • Caution: administer slowly and monitor BP, pulse rate, lung sounds, serum Na, and urine output. Contraindicated in patients with hyperkalemia or lactic acidosis.

  • Isotonic (same osmolarity as body fluid).

• D5W (Dextrose 5% in Water):

  • Tricky: Isotonic in the bag but becomes hypotonic inside the body after glucose metabolizes.

  • Caution: Don't give to infants or head injury patients. May cause cerebral edema. Provides free water and can cause hyponatremia.

• D5 1/2 NS (Dextrose 5% in 0.45% Normal Saline): Hypertonic. Provides both fluid and some calories.

• D5NS (Dextrose 5% in Normal Saline): Hypertonic. Provides fluid, calories, and sodium.

Types of IV Fluids

• Hypertonic:

  • D5 NaCl (Dextrose 5% with 0.9% normal saline). Used to treat severe hyponatremia or cerebral edema.

  • D5 Lactated Ringers (LR) (Dextrose 5% with Lactated Ringers). Provides electrolytes and calories.

  • D5 0.45% (Dextrose 5% with 0.45% normal saline). Used for maintenance fluids.

• Hypotonic:

  • 0.25% NaCl. Provides free water to cells; use with caution due to risk of cellular swelling.

  • 0.45% NaCl (half normal saline). Used to treat hypernatremia.

  • 2.5% Dextrose. Provides minimal calories.

  • 5% Dextrose. Provides minimal calories and free water.

Isotonic Fluids

• 0.9% NaCl (Normal Saline). Expands the extracellular fluid volume.

• Lactated Ringers (also sometimes called Ringers Lactate). Similar to plasma; contains multiple electrolytes.

• D5 water: Isotonic in the BAG but dextrose metabolizes and IV fluid just turns to water. Thus it is HYPOTONIC in the BODY. Provides free water after dextrose is metabolized.

Normal Lab Values

• Sodium: 135-145 mEq/L. Critical for nerve and muscle function.

• Potassium: 3.5-5 mEq/L. Important for cardiac function.

• Magnesium: 1.3-2.1 mEq/L. Involved in muscle and nerve function, blood sugar control, and blood pressure regulation.

• Calcium: 9-10.5 mg/dl. Essential for bone health, muscle contraction, and blood clotting.

Electrolyte Replacement: K and Na

• Imbalances related to meds (furosemide), GI disturbances, kidney disease

• Potassium must be diluted in a large quantity of fluid (at least 250-500cc) because it can cause significant venous discomfort and phlebitis (inflammation of a vein). High alert medication.

• NEVER bolus or IVP K: if given too quickly, it can cause life-threatening arrhythmias. (10mEq/hr). Monitor patient closely during infusion.

• If patient is accidentally bolused:

  1. Assess Patient

  2. Page Provider

  3. Anticipate ECG or continuous telemetry

• If sodium is given too quickly or too concentrated, it can cause neurological damage and phlebitis. Monitor sodium levels frequently.

Vascular Access Devices

• Catheters or infusion ports

• Equipment needed

• Initiating the intravenous line

• Regulating the infusion flow rate: Different pumps vs. gravity

• Maintaining the system

• Monitoring for IV complications

IV Catheter Considerations

• Type of Fluid Infused:

  • Some fluids may require central access or can be caustic to the veins. For these types of fluids, a larger vein may be ideal, or in some cases, central access (central line, peripherally-inserted central catheter [PICC line], etc.) may be warranted.

  • Consider how fast the IV fluids will need to go, so you select the correct size for the ordered flow rate. Select the smallest gauge catheter that will accommodate the prescribed treatment.

• Patient age: Pediatric and geriatric patients may require smaller gauge catheters.

• Duration of infusion (short-term vs Long-term): Long-term infusions may require central venous access.

• IV location: Will they be ambulating to the bathroom? Are they right- or left-handed? Choose a site that does not interfere with the patient's mobility and activities.

• Contraindications for IV present?

IV Catheters

Peripheral Intravenous Catheters (IV)

Indications

• Venous blood sampling

• Intravenous fluid infusion

• Intravenous medication infusion

• Blood transfusion

• Intravenous contrast infusion

Contraindications

• Extremity with significant edema, burns, sclerosis, phlebitis, or thrombosis. Avoid using affected areas.

• Ipsilateral radical mastectomy or fistula. Use the opposite arm if possible.

• Overlying cellulitis. Infection at the insertion site.

Complications

• Early:

  • Bruising. Apply pressure after insertion to minimize bruising.

  • Infiltration. Fluid leaks into surrounding tissue.

  • Air embolism. Prevent by ensuring all connections are tight and tubing is properly primed.

• Late:

  • Phlebitis. Inflammation of the vein.

  • Infection. Use aseptic technique during insertion and maintenance.

  • Nerve damage. Avoid inserting near known nerve locations.

  • Thrombosis. Blood clot formation in the vein.

Complications

• Phlebitis: inflammation of a vein. Can result from chemical, mechanical, or bacterial causes

  • Risk factors: acidic or hypertonic IV solutions, rapid IV rates, IV drugs such as potassium chloride (KCl), vancomycin, penicillin, IV inserted in an area of flexion, poorly secured catheter, poor hand hygiene, lack of aseptic technique

  • Can be dangerous because blood clots can form along the vein and in some cases cause emboli

• Infiltration: IV fluid inadvertently enters subcutaneous tissue around venipuncture site. Coolness, paleness, and swelling of the area. Stop infusion and elevate extremity.

• Extravasation: IV fluid with additives inadvertently enters subcutaneous tissue around venipuncture site. Coolness and swelling of the area, but the additives can cause local tissue damage and sloughing. Stop infusion, notify provider, and follow institutional guidelines for managing extravasation.

Venous Access Devices

• Include the peripheral intravenous (IV), but also include a series of devices that offer central access to the vascular system.

• Central access: the entrance to the device is outside the body, but the tip sits close to the entrance of the heart (usually in the superior vena cava [SVC])

Central Venous Access Device

• Indication:

  • Too difficult to start IV, long-term IV (chemo, antibiotics), caustic medications (levophed), monitoring of hemodynamic status

• Care:

  • Surgical asepsis, inserted by trained nurse or provider, follow insertion by chest X-ray, infused gauze disks may be used to reduce infection, mask worn by PT and RN during dressing change. Changed q3-7 days, flush port with 10 mL of saline every 24 hours. Depending on the catheter, saline with heparin (a blood thinner) may be used.

• Complications:

  • Infection, pneumothorax, embolism, dislodgement, bleeding

Central Lines

• PICC: Peripherally inserted central catheter. Located on the arm. Placed in IR or by specially-trained RN (PICC nurse)

• PAC: Port-a-Cath/Implanted Port. Placed in IR.

• Vascath/Hickman: Located on the chest and sutured in. Placed in IR.

• Central lines are most often inserted through the either subclavian vein. Alternate insertion sites include the internal jugular and femoral veins. All end in the superior vena cava.

• Sterile procedure and sterile dressing change. Requires a consent

• Risk for infection and increase risk for blood clots/DVTs

PICC

• Peripherally inserted central catheter (PICC) lines typically go in the basilic vein around the antecubital area and are threaded all the way into the superior vena cava (SVC). They appear to be a regular intravenous (IV) catheter. These can be kept in place for several months and are treated the same as a central line when considering dressing change schedules, flushing, and using. They can be more comfortable for the client and have less risk than a central line for insertion complications.

Port-a-cath

• Can stay for months to years

• Client may swim/shower

• Implanted

• Access and deaccess (use heparin lock flush)

Packed Red Blood Cells (PRBCs)

• 1 unit PRBCs contains approximately 300 mL of mostly red blood cells. Raises hgb level 1g/per unit. Monitor patient for transfusion reactions.

• Good for pts who have lost blood, are anemic, undergoing cancer treatment (bone marrow isn't making RBCs)

• This unit of blood is given for impaired oxygenation due to low blood count (anemia). It is essential to know the client’s blood type to ensure a correct match is made before transfusion. A difference in blood type can result in a transfusion reaction.

• Rh factor: Rhogam IM inj for Rh neg pregnant woman is considered a blood product and can only be administered by an RN. Prevents antibody formation in Rh-negative mothers.

• People who have O negative blood are considered “universal donors.” While type O negative blood can be given in emergencies when there is no time to obtain a blood type (trauma), type matching should always be done when available.

Other Blood Components

• Platelets (PLT): cells that help blood clot. Good for patients whose bone marrow isn't making these cells. Used to treat thrombocytopenia or platelet dysfunction.

• Fresh frozen plasma (FFP): contains a large number of clotting factors. Good for patients at risk for bleeding due to high levels of blood thinners. Used to treat bleeding disorders or to replace clotting factors in patients with liver disease.

ABO Blood Groups

Storage

• Blood is usually refrigerated to prolong shelf life, which is approximately 42 days at 1° to 6° centigrade. After that period of time, the blood cannot be used. Strict temperature control is critical.

• When a client needs blood, either a type and screen or a type and cross-test are completed. A type and screen is indicated when the client likely won’t need blood, but if, for some reason, they do, half the work is already done. When a type and cross match is done, a client will be matched with a donor unit of blood, and it will be reserved for up to 72 hours. After that time, if the blood is not used, it goes back into the general circulation.

• A very similar process is also completed for clients needing fresh frozen plasma (FFP) or platelets. Close contact with the blood bank at the facility and transport personnel who can pick up the blood products are essential to the blood and blood product administration process.

Transfusion Equipment

• Required items include:

  • blood transfusion tubing (usually a Y set with a clot filter). Prevents clots from entering the patient.

  • normal saline (0.9%) for priming and flushing the tubing. Ensures compatibility with blood products.

• Additional items needed for special circumstances include:

  • Pressure bag: If a client is critically ill or severely anemic and needs a rapid infusion, a bag filled with air is pumped up over the blood bag to force quicker administration. Use with caution to prevent complications.

  • IV pump: Controls the rate of infusion.

  • Blood warmer: Some clients are more sensitive to temperatures and may need the addition of a blood warmer as the product is infusing. Prevents hypothermia.

  • Leukocyte reduction filters: used to catch white blood cells that have not been removed, thereby reducing the risk of a non-hemolytic transfusion reaction.

Administering Blood and Blood Products

• Client issues to consider before preparing to administer blood or blood products:

  • Sensitive to large volumes (for example heart failure). Monitor closely for signs of fluid overload.

  • Unusual antibodies as part of their blood typing. May require special blood products.

  • Religious preferences that exclude the use of blood replacement therapy. Respect the patient's wishes and explore alternatives.

• Some things to do when preparing to administer blood or blood products:

  • Review facility policies and protocols for blood and blood product administration. Ensures compliance and safety.

  • Verify that the donor and client’s blood types are matched. Prevents transfusion reactions.

  • Plan steps to obtain, transport, and store blood or blood products. Maintains blood product integrity.

  • Stay with the client for at least the first 15 minutes of transfusion. Monitor for immediate reactions.

  • Take baseline vitals before the transfusion starts. Provides a reference point for detecting changes.

  • Be sure the catheter size is at least 20 g, and preferably 18 g or larger. Ensures adequate flow rate.

  • Use blood tubing for administration.

Common Steps for Blood & Blood Product Administration

• Inform the client of the procedure and possible complications. Gather supplies, wash hands, and put on gloves.

• Check and verify the client's wristband with blood bank name and label, blood type of donor and recipient match, and a hospital ID number. This is usually done with another nurse (check the facility policy).

• Spike and prime FILTERED blood Y-tubing with 0.9% normal saline.

• Spike and hang the blood and flush through to the hub of the tubing.

• Collect the client’s baseline vital signs, including temperature.

• Start blood administration slowly.

• Recheck vital signs after 15 minutes, addressing any abnormalities immediately.

• Documentation usually includes a label on the bag and the time the blood is started.

Blood Transfusion Reactions

• Most signs of a transfusion reaction indicate immediately stopping the blood or blood product, disconnecting the intravenous (IV) line, and replacing it with a new line running 0.9% normal saline. Maintain patent IV access.

Transfusion Reaction Types

• Transfusion Associated Circulatory Overload (TACO)

  • Cause: excess fluid volume

  • This can occur with clients with history heart failure, liver failure, renal failure

  • Symptoms: tachycardia, crackles, JVD, hypertension, edema, dyspnea, orthopnea. Manage by slowing or stopping the transfusion and administering diuretics.

• Febrile Non-hemolytic

  • Cause: Antibodies attack white blood cells (WBCs).

  • This reaction is caused by the recipients' antibodies attacking white blood cells located in the donor’s blood. This is the most common type of reaction.

  • Symptoms: fever, chills, headache, anxiety, and muscle pain. Manage with antipyretics and antihistamines.

• Acute Intravascular hemolytic

  • Cause: Antibodies attack red blood cells (RBCs).

  • This is the reaction to receiving incompatible blood in which the donor does not match the recipient. The recipient's antibodies attach to antigens on the donor’s red blood cells, causing the cells to be destroyed.

  • Symptoms: fever, chills, low back pain, flushing, fast breathing and heart rate, low blood pressure, blood in the urine, suddenly reduced urination, shock, cardiac arrest, and death. This is a life-threatening reaction; immediate intervention is required.

• Anaphylactic

  • Cause: Antibodies attack plasma.

  • This reaction occurs when the recipient’s allergy antibodies (Anti-IgA) attack the donor’s plasma.

  • Symptoms: hives, shortness of breath, wheezing, cyanosis, hypotension, shock, and death. Treat with epinephrine, antihistamines, and corticosteroids.

• Mild allergic

  • Cause: Antibodies attack plasma proteins.

  • This reaction occurs when the recipient’s antibodies attack plasma proteins in the donor’s blood.

  • Symptoms: flushing, itching, and hives (urticaria). Treat with antihistamines.

STOP, Change, Report, Remain, Prepare, Save, and Collect

• Stop the transfusion immediately.

• Change the intravenous (IV) tubing down to the catheter hub with new tubing and run 0.9% sodium chloride (normal saline). Do not use tubing with the remaining donor blood present.

• Report to the healthcare provider or emergency response team.

• Remain with the client, record signs and symptoms, and monitor vital signs at 5-minute intervals.

• Prepare to administer emergency drugs such as antihistamines, vasopressors, fluids, and corticosteroids per the healthcare provider's order or protocol. Prepare to perform cardiopulmonary resuscitation.

• Save the blood container, tubing, attached labels, and transfusion record for return to the blood bank.

• **Collect