Maintain fluid & electrolyte balance

Hydration

Maintenance

Fluid Volume Maintenance

Electrolyte Balance

Fluid Volume Replacement

Medication Administration

Transfusion of Blood & Blood Products

Provide Nutritional Supplementation

Monitor hemodynamic functions

Administer diagnostic reagents

Total Parenteral Nutrition (TPN) (Hyperalimentation)

Peripheral Parenteral Nutrition (PPN)

Swan Ganz Catheter

ART Line

IVP DYE

CT Contrast

Nuclear Medicine Dye

Daily weights

I & O

Lab Values

Skin Turgor

Mucous Membranes

LOC

Gain = I > O

Loss = O > I

MUST be accurate & correct

Hct

BUN

Creatinine

Osmolality

Specific Gravity

% by volume of RBC in WB

Females 38--47%

Males 40--54%

Increases with dehydration

Decreases with fluid overload and anemia

Reflects protein intake & renal excretory capacity

8--23 mg/dl

Increases with dehydration

Decreases with fluid overload

Measures the glomerular filtration rate

0.6--1.5 mg/dl

Increases with renal disease/dysfuntion

50% or > =nephron damage

Measures # of particles in body H2O which exert osmolar pull

280--295 mOsm/kg

Increases with dehydration

Decreases with fluid overload

Measures kidneys ability to concentrate urine

1.001--1.035

Increases with dehydration

Decreases with Acute Renal Failure or tubules lose ability to concentrate urine

Decreases with dehydration

Increases with fluid overload

Decrease with dehydration

Increased confusion with dehydration

Dry and cracked with dehydration

Clinical Picture—status of patient

Assessment Data

Clinical Status (existing imbalance)

Patient Needs

Avoid Creating New Problems

Equal to the concentration in the cell.

Close to the same osmolarity as serum. They stay inside the intravascular compartment, thereby expanding it.

Can be helpful in hypotensive or hypovolemic pts

Can be harmful. There is a risk of overloading, especially in pts with CHF and HTN

Examples: LR and NS

Less concentration in the cell

Moves into the cell to rehydrate

Has less osmolarity than serum

Can be helpful when cells are dehydrated.

May be used for DKA

Can be dangerous to use because of the sudden shift from the intravascular space to the cells.

Examples: D5NS.45%NaCl(1/2NS) & 2.5%dextrose

Greater concentration in cell

Draws fluid from cell (edema)

Has a higher osmolarity than serum

Can help stabilize BP, increase UO and reduces edema

Rarely used in Pre-hospital setting

Dangerous with cell dehydration

Examples: D5%, D5LR, D5NS, D10%W, D5%W, blood products, and albumin

Solutes, which when placed in a solvent, homogeneously mix with it, dissolve and cannot be distinguished from the resultant solution. They are able to diffuse through membranes.

Such infusions are usually electrolyte solutions that may be isotonic, hypotonic or hypertonic.

Glutinous substances whose particles, when submerged in a solvent, cannot form a true solution because their molecules do not dissolve, but remain uniformly suspended and distributed in the fluid.

Colloid infusions expand volume by raising colloid osmotic pressure

Infusions that supplement caloric intake, supply nutrients, and provide free water for maintenance, hydration, or to promote effective renal output.

Carbohydrates in water

Carbohydrates in Sodium Chloride Solution

Sodium Chloride Solution

Electrolytes Solution

5% Dextrose in water (D5W) (ISOTONIC/HYPOTONIC)

10% Dextrose in Water (D10W) (HYPERTONIC)

prevents dehydration

prevents & treats ketosis

Promotes sodium diuresis

Supplies calories & water

Vehicle for I.V. Medications

5% Dextrose in 0.2% Sodium Chloride (D50.2NaCl) (ISOTONIC)

5% Dextrose in 0.45% Sodium Chloride (D50.45NaCl) (HYPERTONIC)

5% Dextrose in 0.9% Sodium Chloride (D50.9NaCl) (HYPERTONIC)

Promotes diuresis, Prevents alkalosis, Corrects moderate fluid loss, Provides calories and sodium chloride

0.45 Sodium Chloride (0.45 NaCl) (1/2 Normal Saline)

0.9 Sodium Chloride or NSS (0.9 NaCl) (Normal Saline

3% Sodium Chloride (3%NaCl)

5% Dextrose in Lactated Ringer’s (D5LR)

Lactated Ringers (LR)

5% Dextrose in Ringers (D5R)

Ringers Solution

Potassium

Magnesium

Vitamins

Lipids

KCl

Added by pharmacy (usually)

60-80 mEq/Liter

30-50 mEq/500 cc

<10 mEq/ Hr

Irritating to veins

Check K+ and Cl- before administration

ALWAYS DILUTE

DEADLY IF GIVEN IVP

Mag Sulfate

99% excreted by kidney

Do not infuse rapidly

Calcium Gluconate –Antidote (KNOW THIS)

In Liter of main IV fluid

Inadequate oral intake

Vitamin deficient

Increased stress

Surgery

Burns

IV therapy >3days

Given to increase caloric intake

Fat emulsion

Nutritional supplements

Available 10% or 20%

More than twice the calories of proteins or carbohydrates

Peripheral IV (PPN) or Central Line (TPN)

DO NOT ADD ANYTHING TO SOLUTION

Hypertonic Solution

Total Parenteral Nutrition

Hyperalimentation

Ordered by Physician & Dietician

Infused into large central vein

Mixed by Pharmacist

Store in refrigerator until used

DO NOT ADD ANYTHING TO IT!!!

25% dextrose (Carbs)

3-4% amino acids (proteins)

Fats as lipids

Potassium

Various electrolytes

Vitamins & Trace elements

Regular Insulin

Sometimes Heparin

10% Amino Acid Inj 800ml

Dextrose 50% in Water 500ml

Fat Emulsion 10% 500ml

Potassium PO4 Inj 21mmol/7ml

Sodium Chloride 70mEq/17.5ml

Potassium Chloride 30mEq/15ml

Zinc Chloride 4mg/4ml

Phyonadione 1mg/0.5ml inj 1mg/0.5ml

Trace minerals 1 ml

Insulin Regular (Human) 15units/0.15ml

Famotidine 40mg/4ml

Heparin Sodium 1000units/ml 1000units/1ml

Mag Sulfate 50% (4mEq/ml) Inj 2.5Gm/5ml

Ca Gluconate 0.465 mEq/ml Inj 10mEq/21.5 ml

Multivitamin Inj 10ml

_______________________Total 1881.66 ml

Infuse over 24 hours 78.4 ml/hr

Expiration -- -- --

Refrigerate--DO NOT FREEZE

1) The TPN catheter or CVC lumen is not to be used for anything other than the delivery of parenteral nutrition.

2) Verify that the ordered infusate is correct for the pt. Check the expiration date & time.

3) A container of TPN must not infuse beyond a 24 hour period. Be sure the next container is ready to hang before the previous one infuses. Should the next one not be ready, a 10% dextrose infusion to which 50% dextrose(D50) is added must be hung to prevent rebound hypoglycemia. Refrigerated TPN solution must be removed 1 hour prior to infusion.

4) When TPN is initiated, the infusion should be started at a relatively low rate (approx 50cc/hr) to preclude hyperglycemia. The rate should be increased at a rate of 25ml/hr until the ordered rate is being infused.

5)The infusion must be maintained at the prescribed rate. The rapid infusion of TPN can cause hyperosmolar diuresis, seizures coma and even death.

6) TPN should be administered using a pump

7)Vital signs should be monitored Q4 or more frequently

8)Daily weights. Monitor I&O carefully

9)Adequate oral intake must be assessed prior to DC

10)Pt must be weaned from TPN to avoid rebound hypoglycemia. Usually over a 24 hour period.

Monitor carefully

Begin infusion slowly

Taper off if discontinuing dose

Use Pump

Keep on Time (do not change rate)

Check blood sugars

DO NOT PLAY CATCH UP

DO NOT STOP FLOW ABRUPTLY

Aseptic Technique

DO NOT INTERRUPT LINE

Sterile dressing changes

Valsalva maneuver

Rapid absorption

Immediate action

Continuous administration

Immediate Termination

Usually mixed with NS or D5W

Rate 50cc/30 minutes or 100cc/1 hour

Products Available

PRBC’S

Others

Check physician orders

Draw a type and crossmatch

Verify patient with arm band vs. MR# on blood product bag, blood type, and expiration date

Administer through 19ga or larger needle

Administer only with NS

Assess cardiac and pulmonary status before transfusion is started.

Monitor VS before, during, and after infusion

Stay with patient first 15 minutes of infusion to check for s/s of reaction

Safety Procedures

Types of IV devices

Equipment

Site Selection

Preparation

Procedure

Charting

Physician’s Order READ CAREFULLY

Patient ID ALWAYS MAKE SURE YOU HAVE THE RIGHT PATIENT

1000cc D51/2NS with 40 mEq Kcl @ 200cc/hr times 2liters. Then change fluids to 1000cc D51/2 NS with 20 mEq Kcl @ 100cc/hr.

Angiocaths

Winged "Butterfly" catheters-portacath insertion

Midline catheter (MLC) (1-4 weeks)

CVD (central vascular devices)

PICC (Peripherally inserted central catheter)

Triple Lumen Central Line

Hickman (Right Atrial Catheter)

Groshong (Right Atrial Catheter)

Implanted venous access devices (Porta-cath)

PROBLEM

Catheter related sepsis

Catheter tip in Right atrium

Drainage from exit site

Redness, pain at exit site

Fever spike

Sudden increase in HR

Decrease in external catheter length

PROBLEM

Catheter tip in Jugular vein

Catheter malfunction

Pt hears bubbling in ear when catheter is flushed

Sudden earache on side of catheter

Crepitis

Inability to infuse fluid @ prescribed rate

No blood return or must reposition pt for blood return

Arm swollen on catheter side

Visible collateral chest veins

Solution & Tubing

Pump & pole

Various Needles/Angiocaths

IV Start kit or tape, betadine, ETOH wipes, tourniquet & dressing

Towel

Gloves

What

Why

Where

How long

Identify fear & anxiety

Pain

Decreased mobility

Wash Hands, Wash Hands, Wash Hands

Spike fluids & prime tubing

Have pump /or pole ready

Have various size needles

Tear tape

Towel to protect bedding--saves extra work & expense

Good light

Position Patient

Patient preference

?CVA,?Mastectomy???

Avoid areas of flexion

Consider medical hx, age, size, general condition, level of activity

Type if infusion

Expected duration of IV therapy

Foot, leg & ankle veins

Veins below a previous IV infiltration

Veins below a phlebitic area

Sclerosed or thrombosed veins

Areas of skin inflammation, disease, bruising or breakdown

An arm effected by radical mastectomy, edema, blood clot or infection

An arm with an arteriovenous shunt or fistula

3/4 to 1 1/4 inches long

Consider condition and Type of solution

24-22 gauge for children & elderly

24-20 gauge for medical & post--op pts

18 gauge for surgical

16 gauge for trauma pts

Wash hands

Gloves

Tourniquet

Cleanse site with ETOH &betadine & ETOH

Insert needle/observe for blood return

Thread vein & connect tubing

Release tourniquet

Stabilize Site w/tape and apply dressing

Loop & Tape tubing

Date & Initial dressing

Latex allergies???

4-6 inches above venipuncture site

Should be able to palpate distal pulse

Gravity

Milking

Tapping

Fist Clenching

Warm compress

DO NOT SHAVE--clip hair if necessary

Cleanse site

DO NOT CONTAMINATE AFTER CLEANSING

Gloves on

Site cleaned

Tourniquet in place

Pull skin taught--distally

Insert needle--bevel up @ a 20-30 degree angle, with the venous flow

Observe blood return, thread vein, release tourniquet, attach tubing, stabilize IV with tape & dressing

Loop & tape tubing

Date & time,Type and gauge of the needle

# of attempts

Site(exact location)

Type of dressing applied

Pt’s response

Special precautions(positional, armboard, pumps)

Fluid type, amount & rate

Parenteral fluid sheet I & O

Solution

Tubing

Site

Assessment Parameters

Patient teaching

Do Not hang longer than 24 hours

Never let run dry

Change according to hospital policy

Ensure all connections are secure

Needle

Dressing

Do not kink, compress or lie on tubing

Avoid using the IV arm to eat, hygiene…

DO NOT adjust clamp or change level of bag

When walking--call for help, don’t pull on tubing, use IV pole, bend arm at waist.

Call nurse when--bag is low/empty, any wetness/blood, pain, burning, swelling, alarming pump...

Assess for redness, blood, edema, drainage, leakage.

Check fluid level, pt tolerance & tubing patency q1-2 hours

Avoid BP in IV arm when possible

Check if tubing is kinked or clamped

Avoid placement in dominant hand

Local discomfort

Infiltration

Phlebitis

Circulatory Overload

Air Embolism or Catheter Embolism

Infection

Speed shock

Allergic reaction

Fluid overload

Pain at the site of needle or catheter insertion or in the vein from infusate.

Infiltration is the leakage of fluid outside the vein into the surrounding tissue.

Occurs due to the needle/catheter displaced from the vein (partial or complete

Leakage of blood around needle or catheter (especially likely in an older pt whose tissues have lost their elasticity)

Pain

Blanching or Coolness of skin around site

Pallor

Swelling

Tight skin

Damp or wet dressing

No blood return

Sluggish flow rate or not any flow at all

Stop infusion

Remove catheter

Ice/warm compress????

Restart IV

Document what you have done

Use a splint to stabilize the needle/catheter when the site is over a joint or the pt is active.

Palpate occasionally to confirm proper needle position. When a needle is placed correctly in a superficial vein, you can usually feel it easily.

Frequent assessment and good nurse/patient communication is key.

Injury to the vein, either during venipuncture, from needle movement later or possibly from meds such as Kcl, ABC’s, or TPN.

Irritation to the vein caused by long term therapy, irritating or incompatible additives, or uses of a vein that is too small to handle the amount or type of solution.

Sluggish flow rate which allows a clot to form at the end of the needle/catheter

Sluggish flow rate

Edema in limb

A vein that is sore, hard, or cordlike and warm to the touch. It may look like a red line above the venipuncture site.

Aching or burning sensation at infusion site

Elevation in temp 1 degree or more above baseline

Throbbing pain in limb

Mottling, cyanosis, or pallor of the extremity

Diminished arterial pulses

DC the infusion and remove the needle/catheter immediately

Apply warm wet compresses

Notify Physician

Restart IV in another limb

Document what you have done

If you have to use an irritating additive. Try to find a vein large enough to dilute it.

Dilute irritating additives with diluents, if possible.

Make sure drug additives are compatible.

Keep the infusion flowing at the prescribed rate.

Stabilize the needle/catheter with a splint if necessary.

TOO MUCH FLUID">)

Fluid delivered too fast

Rise in blood pressure or central venous pressure (CVP)

Dilatation of veins, neck veins sometime visibly engorged.

Rapid breathing, shortness of breath, rales

Wide variance between liquid input and urine output

Slow infusion to KVO rate

Keep Pt’s head elevated

Keep Pt warm.

Monitor VS

Administer O2 if permitted

Notify Physician

Document what you have done

Be aware of the pt’s cardiovascular status and history.

Tell the doctor if the fluid volume or flow rate may be more than the pt can tolerate

Carefully monitor the pt’s urine output.

Container allowed to run dry

Air in tubing

Loose connections

Extreme anxiety--fear of impending death

Light-headedness & confusion

Nausea

Drop in blood pressure

Rise in CVP

Weak, rapid pulse

Cyanosis

Loss of consciousness

Substernal pain

Turn pt on left side and lower the HOB

Check system for leaks

Give O2 if allowed

Notify Physician Immediately

Document what you have done

Clear ALL air from tubing before attaching it to the pt.

Change containers before they are empty

Make sure ALL connections are secure

Withdrawing the catheter before the needle or attempting to rethread a catheter with a needle.

Failure to secure the catheter to the skin adequately

Sudden & severe discomfort along the vein in which the catheter fragment is lodged.

Drop in BP

Rise in CVP

Weak, rapid pulse

Cyanosis

Loss of consciousness

DC IV

Apply tourniquet above site

Have pt X-rayed

Call Physician

Document what you have done

Remember to withdraw the needle & catheter together after unsuccessful venipuncture attempt

Take special care when withdrawing an inside-the-needle catheter

POOR aseptic technique such as: Not washing your hands, failure to keep the site clean or to change IV equipment regularly.

Contamination of equipment during manufacturing, storage or use

Irrigation of clogged IV

Swelling & soreness at site

Foul smelling discharge

Sudden rise in temp and pulse

Chills & shaking

BP changes

DC infusion & remove needle/catheter immediately.

Send IV equipment to lab for bacterial analysis

Culture the drainage

Clean site, apply antibiotic ointment & cover with sterile gauze pad

Restart IV in another limb

Document what you have done

Look for other sources of infection. Culture urine, sputum, & blood as ordered

Review and improve aseptic technique

Remember to wash your hands thoroughly before beginning any IV procedure

Drugs administered too quickly

Improper administration of bolus infusions

Flushed face

Severe POUNDING Headache

Feeling of apprehension

Tight feeling in chest

HTN

Irregular pulse/tachycardia

Loss of consciousness

Cardiac Arrest

Dyspnea

DC drug infusion

Start KVO fluids

Notify Physician immediately

Document what you have done

Keep main line IV flowing at prescribed rate.

Don’t give medications faster than recommended

Sensitivity to an IV fluid or additive

Latex

Betadine

Tape

Itching

Rash

SOB

Anaphylaxis

Slow infusion to KVO if minor

Stop infusion if major

Notify Physician

Ask pt if they have an allergy before beginning venipuncture.

Check for armband

If pt reports allergy--check it out

They may have a sensitivity to iodine used as a skin prep.

Microdrip=60gtts

Macrodrip=10-15gtts

Mls/hr total volume in mls

ml/hr = ---------------------------

total time in hours

Ml/min = ml 1hour

----- X -------

hr 60 minutes

(Volume in Mls) X (Drip set) gtts _______________________ = _____

(Time in minutes) Min

Drops per minute

(250ml) X (10gtts/min) gtts

___________________ = ____

(90 minutes) 1 min

2500 gtts

_____ = ___

90 1

2500 / 90 = 27.77 X 1 =28gtts/min(since we round up)

Pt weighs 220 # (220#/2.2==100kgs)

Give 1 amp D50

Med should be given at 0.5 mg/kg

Formula 0.5mg ?mg _____ = ____ 1 1 Kg 100kg We are solving for X

So 0.5mg X 100kg / 1 kg =50mg which is 1 amp D50--isn’t nice how that worked out:>)

Remember the 5 rights: The minimum standard of practice for medication administration is checking the 5 rights

Right patient

Right drug

Right dose

Right time

Right route

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