Lecture 7: IV Therapy and Fluid Balance

‭Two Compartments of Bodily Fluid‬ ‭ ‬ I‭ ntracellular fluid (ICF): 70%‬ ● ‭●‬ ‭Extracellular fluid (ECF): 30%‬ ‭○‬ ‭Intravascular fluid (¼)‬ ‭○‬ ‭Interstitial fluid (¾)‬ ‭Functions of Water‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭ orms saliva (digestion)‬ F ‭Needed by the brain to manufacture hormones and neurotransmitters‬ ‭Keeps mucosal membranes moist‬ ‭Regulates body temperature (sweating and respiration)‬ ‭Allows the body’s cells to grow, reproduce, and survive‬ ‭Acts as a shock absorber for the brain and spinal cord‬ ‭Flushes body waste, mainly in the urine‬ ‭Converts food to components needed for survival - digestion‬ ‭Lubricates joints‬ ‭Acts as the major component of most body parts‬ ‭Helps deliver oxygen all over the body‬ ‭Variations in Fluid Content‬ ‭Age‬ ‭●‬ A ‭ dults: Fluid content = 50-60% of body weight‬ ‭●‬ ‭Infants: Fluid content = 75% of body weight‬ ‭○‬ ‭More prone to fluid volume deficits (FVD)‬ ‭Biological Sex‬ ‭●‬ ‭Women: ↑ body fat, ↓ fluid content‬ ‭●‬ ‭Men: ↓ body fat, ↑ fluid content‬ ‭Body Fat‬ ‭●‬ ‭Muscle cells: Rich in water‬ ‭●‬ ‭Fall cells: Little water‬ ‭○‬ ‭Obese people‬ ‭○‬ ‭Women‬ ‭○‬ ‭Older adults‬ ‭○‬ ‭↑ fat cells and ↓ muscle cells = ↓ bodily fluid content‬ ‭Question:‬‭Weight is the best parameter to indicate‬‭overall fluid status.‬ ‭a.‬ ‭True‬ ‭b.‬ ‭False‬ ‭Osmosis‬ ‭‬ S ● ‭ olutes:‬‭The substance dissolved in a given solution‬ ‭●‬ ‭Solvents:‬‭Liquids that can dissolve other substances‬ ‭●‬ ‭Process of Osmosis:‬‭Water (the solvent) passes from‬‭an area of less solute concentration‬ ‭and more water to an area of more solute concentration and less water until equilibrium is‬ ‭established‬ ‭Osmolarity of a Solution‬ ‭ ‬ I‭ sotonic:‬‭Same concentration of solute particles as‬‭plasma‬ ● ‭●‬ ‭Hypertonic:‬‭Greater concentration of solute particles‬ ‭than plasma‬ ‭●‬ ‭Hypotonic:‬‭Less concentration of solute particles than‬ ‭plasma‬ ‭Isotonic Solutions‬ ‭●‬ ‭5% dextrose in water (D5W):‬ ‭○‬ ‭Isotonic in bag → hypotonic upon dextrose metabolism‬ ‭○‬ ‭Good for hypernatremia, dilutes the blood more‬ ‭●‬ ‭0.9% NaCl (normal saline):‬ ‭○‬ ‭Matches plasma levels well‬ ‭○‬ ‭Only solution given with blood transfusions‬ ‭●‬ ‭Lactated Ringer’s solution:‬ ‭○‬ ‭Contains lactose, potassium, etc.‬ ‭○‬ ‭Good for an acidotic patient; transforms into bicarbonate‬ ‭■‬ ‭Unless in lactic acidosis‬ ‭ uestion:‬‭A hypertonic solution has greater osmolarity,‬‭causing water to‬ Q ‭move out of the cells and to be drawn into the intravascular compartment,‬ ‭causing the cell to shrink.‬ ‭a.‬ ‭True‬ ‭b.‬ ‭False‬ ‭Fluid Imbalances‬ ‭●‬ O ‭ ccurs when the body fails to compensate for a loss of homeostasis involving volume,‬ ‭distribution of water, or electrolytes‬ ‭Fluid Volume Deficit‬ ‭Hypovolemia‬ ‭●‬ ‭Isotonic fluid loss; proportional loss of water and solutes from ECF space‬ ‭●‬ L ‭ oss of volume in blood vessels → interstitial fluid into intravascular space → interstitial‬ ‭space becomes hypertonic → cellular fluid into interstitial space → cells cannot function‬ ‭●‬ ‭Cause:‬‭Loss of bodily fluids, especially with a decreased‬‭fluid intake‬ ‭●‬ ‭Risk:‬‭Young children (10% weight loss), older adults‬‭(5% weight loss), ill patients‬ ‭○‬ ‭> 15% weight loss = life-threatening‬ ‭Third-Space Fluid Shift‬ ‭●‬ ‭Bodily fluid movement from intravascular space to transcellular compartments, joint‬ ‭cavities, the bowel, or interstitial space (in accumulation)‬ ‭●‬ ‭Leaders to decreased ECF volume since fluid is trapped and cannot be used‬ ‭●‬ ‭No weight loss occurs; fluid loss is immeasurable‬ ‭●‬ ‭Causes:‬‭Decreased albumin, excess IV fluid replacement,‬‭renal dysfunction, heart‬ ‭failure, hyponatremia, gross tissue trauma,‬ ‭burns, acute intestinal obstruction, heart or‬ ‭liver failure, crush injury, surgical‬ ‭procedure, or acute peritonitis‬ ‭Fluid Volume Excess‬ ‭●‬ E ‭ xcessive retention of both water and‬ ‭sodium in extracellular fluid‬ ‭Hypervolemia and Edema‬ ‭●‬ ‭Hypervolemia:‬‭Fluid build-up in blood‬ ‭vessels‬ ‭●‬ ‭Edema:‬‭Fluid build-up in interstitial space‬ ‭○‬ ‭Often seen in the fingers, ankles, sacral space, in/around organs, or around eyes‬ ‭●‬ ‭Causes:‬‭Fluid overload (excess intake of water and/or‬‭sodium)‬ ‭○‬ ‭Bodily failure to maintain homeostasis‬ ‭○‬ ‭Kidney malfunctions → waste cannot be excreted‬ ‭○‬ ‭Heart pump failure → fluid build-up in the lungs and other parts of the body‬ ‭●‬ ‭Risk:‬‭Up to 5% weight gain‬ ‭Interstitial to Plasma Shift‬ ‭●‬ ‭Fluid movement from the interstitial space into blood vessels‬ ‭●‬ ‭Body prioritizes maintaining intravascular fluid (plasma) spaces over interstitial and‬ ‭intracellular fluid spaces‬ ‭Hypovolemia vs. Dehydration‬ ‭Hypovolemia‬ ‭Dehydration‬ ‭Extracellular fluid volume is reduced, results‬ ‭in decreased tissue perfusion‬ ‭Water loss alone is termed as “dehydration”‬ ‭Can be produced by salt and water loss (e.g.‬ ‭with vomiting, diarrhea, diuretics, or‬ ‭third-spacing‬ ‭Pure water-loss comes from total body water,‬ ‭only about ⅓ of this is ECF‬ ‭Salt and water loss comes from extracellular‬ ‭fluid‬ ‭Always hypernatremic‬ ‭Tx: Salt-based “crystalloid” infusion‬ ‭Tx: Free water administration‬ ‭Edema‬ ‭‬ E ● ‭ xcessive retention of water and sodium in ECF‬ ‭●‬ ‭Located in interstitial space; swelling‬ ‭Pitting Edema‬ ‭‬ M ● ‭ ost common‬ ‭●‬ ‭Characterized by an indentation in the skin that lasts when pressure is applied‬ ‭Grades‬ ‭●‬ ‭Grade 1:‬‭2 mm‬ ‭●‬ ‭Grade 2:‬‭3-4 mm‬ ‭●‬ ‭Grade 3:‬‭5-6 mm‬ ‭●‬ ‭Grade 4:‬‭7-8 mm‬ ‭○‬ ‭Caused by excess fluid leaking from the capillaries, heart failure‬ ‭○‬ ‭Treated with diuretics‬ ‭Non-Pitting Edema (Brawny Edema)‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭ luid builds up in the body and does not leave an indent upon pressure application‬ F ‭Tissue is firm/hard‬ ‭Skin is shiny, warm, red, dark, and moist‬ ‭Usually localized to the limbs‬ ‭Caused by conditions that affect the thyroid and lymphatic systems‬ ‭Causes‬ ‭●‬ ‭Lymphedema:‬‭Built up/blockage of lymph tissue‬ ‭●‬ ‭Myxedema:‬‭Thyroid issues‬ ‭○‬ ‭Pretibial edema:‬‭Legs‬ ‭○‬ ‭Periorbital edema:‬‭Eyes‬ ‭●‬ ‭Angioedema:‬‭Allergic reaction‬ ‭ ‬ ‭Face, tongue, abdomen, arms, legs‬ ○ ‭ ‬ ‭Lipedema:‬‭Build-up of fat under skin‬ ● ‭Treatment‬ ‭●‬ ‭Exercise, elevation, compression, medications (depending on the type)‬ ‭Risk Factors for Imbalances‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭ omiting: Loss of fluid = dehydration‬ V ‭Diarrhea: Loss of fluid = dehydration‬ ‭Hemorrhage: Plasma includes 90% water and essential minerals‬ ‭Sweating: Water and sodium loss‬ ‭Burns: Skin damage and fluid leak‬ ‭Therapies that disrupt fluid and electrolyte balance: Constant changes in fluid‬ ‭Veins of the Shoulder and Upper Limb‬ ‭Deep Veins‬ ‭●‬ ‭Radial and ulnar veins (paired)‬ ‭●‬ ‭Brachial vein that connects with axillary vein‬ ‭Superficial Veins‬ ‭●‬ ‭Basilic vein (becomes axillary vein)‬ ‭●‬ ‭Cephalic vein‬ ‭Axillary Vein‬ ‭●‬ ‭Becomes subclavian vein beneath clavicle‬ ‭Peripheral Venous Access Sites‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭ ephalic vein‬ C ‭Basilic vein‬ ‭Accessory cephalic vein‬ ‭Dorsal metacarpal vein‬ ‭Complications of IV Infusions‬ ‭●‬ ‭Infiltration:‬‭Swelling, ↓ flow rate, pallor‬ ‭○‬ ‭Remove immediately; not salvagable‬ ‭●‬ ‭Phlebitis:‬‭Swollen, ↓ flow rate, red, tender, warm‬ ‭●‬ ‭Sepsis:‬‭Bloodstream infection‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭ hrombus:‬‭Clot‬ T ‭Thrombophlebitis:‬‭Inflammation of the vein due to‬‭a clot‬ ‭Air embolism:‬‭Air bubble that can lodge as an embolus‬ ‭Speed shock:‬‭Shock of different IV medication entering‬‭body‬ ‭○‬ ‭Headache, dizziness, malaise‬ ‭○‬ ‭Discontinue medication‬ ‭○‬ ‭Concern with quick medication (bolus) or non-isotonic solution (saline)‬ ‭ ‬ ‭Fluid overload:‬‭Administering too much solution‬ ● ‭○‬ ‭NPO; IV fluid may not be needed any longer‬ ‭Vascular Access Devices‬ ‭●‬ ‭IV tubing should be changed every 3 days‬ ‭Peripheral Venous Catheters‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭ hort catheter (< 3 inches)‬ S ‭Over-the-needle catheters‬ ‭Small; less invasive‬ ‭Rotate the sites every 3-4 days for adult‬ ‭Bevel at 10-30 degree angle‬ ‭○‬ ‭Smaller hole than actual needle‬ ‭Midline Peripheral Catheter‬ ‭‬ L ● ‭ onger catheter (> 3 inches)‬ ‭●‬ ‭In for longer; 2-6 weeks‬ ‭○‬ ‭Ex. IV antibiotics‬ ‭●‬ ‭Blood can be drawn‬ ‭●‬ ‭The tip dwells in axillary vein and distal to the shoulder‬ ‭●‬ ‭Not central line; not the same medications used in each‬ ‭Central Venous Access Devices (CVAD)‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭ erminates in the superior vena cava just about the right atrium‬ T ‭Larger catheter size needed‬ ‭Feeds into a larger blood vessel‬ ‭Very hyperosmolar or vesicant (blistering, irritating) solutions‬ ‭Requires radiographic confirmation of position‬ ‭Types of CVADs‬ ‭●‬ ‭Peripherally inserted central catheters (PICCs)‬ ‭○‬ ‭Appear like a midline but central‬ ‭○‬ ‭Distends all the way to the SVC‬ ‭ ‬ ‭For long-term therapy (6 months)‬ ○ ‭○‬ ‭Median cubital vein connects cephalic and basilic vein at antecubital fossa‬ ‭○‬ ‭This site can be used for PICC‬ ‭ ‬ ‭Tunneled percutaneous central venous catheters‬ ● ‭○‬ ‭Inserted into the internal or external jugular or subclavian vein, then passed under‬ ‭the skin to a separate exit point‬ ‭○‬ ‭Tunneled:‬ ‭○‬ ‭Percutaneous:‬ ‭○‬ ‭Minimize the risk of infection‬ ‭■‬ ‭Placed under the skin, away from the venous access site → prevent skin‬ ‭bacteria from entering the bloodstream‬ ‭○‬ ‭Long-term therapy (6 months)‬ ‭■‬ ‭Tunneling secures long-term catheter use → ideal for extended medication‬ ‭and fluid infusions‬ ‭○‬ ‭Length is > 8 cm (average 90 cm), depends on patient size‬ ‭○‬ ‭Tunneled in subcutaneous tissue under the skin around teh mid-chest area for 3-6‬ ‭inches to its exit site‬ ‭●‬ ‭Nontunneled percutaneous central venous catheters‬ ‭○‬ ‭More emergent; exposed and vulnerable‬ ‭○‬ ‭Faster and more efficient insertion‬ ‭○‬ ‭Short dwell time (3-10 days)‬ ‭■‬ ‭Position and infection vulnerability‬ ‭●‬ ‭Implanted ports‬ ‭○‬ ‭Makes it easier to access a vein, so medications can be administered without‬ ‭significant pressure changes‬ ‭○‬ ‭Less needle sticks; easier to draw blood and get large amounts of medicine/fluids‬ ‭○‬ ‭For patients with:‬ ‭■‬ ‭Serious infection (antibiotics)‬ ‭■‬ ‭Cancer (chemotherapy)‬ ‭■‬ ‭Inflammatory bowel disease (IV treatment)‬ ‭■‬ ‭Kidney failure (dialysis)‬ ‭■‬ ‭Frequent bloow draws, blood transfusions, or IV treatments‬ ‭○‬ ‭At home care:‬ ‭■‬ ‭Numbing cream PRN‬ ‭■‬ ‭Sterilize the skin with an antiseptic‬ ‭■‬ ‭Place sterile dressing on the skin covering the port‬ ‭■‬ ‭Insert needle into the port into septum (portion of port closest to the skin)‬ ‭■‬ ‭Administer medicine or draw blood; remove needle when finished‬ ‭■‬ ‭Insert second needle to flush device with solution; prevents blood clots‬ ‭■‬ ‭Remove needle and bandage injection site‬ ‭○‬ ‭Types:‬ ‭■‬ ‭Single lumen: One access point (most common)‬ ‭■‬ ‭Double lumen: Two access points‬ ‭■‬ ‭Power-injectable: Single or double lumen that can be injected with‬ ‭contrast dyes for CT scans and MRI‬ ‭○‬ ‭Benefits:‬ ‭■‬ ‭At home tx, fewer needle sticks, multiple blood tests or tx in one day, tx‬ ‭tend to last longer‬ ‭■‬ ‭Reduces risrks of leaking and vein damage‬ ‭○‬ ‭Risks:‬ ‭■‬ ‭Infections (most common complication); sepsis‬ ‭■‬ ‭Blockages, blood clots, pneumothorax, faulty port, embolism, hemothorax‬ ‭Administering Medication by IV Bolus‬ ‭‬ P ● ‭ ush according to prescribed rate‬ ‭●‬ ‭Ensure it is compatible with what is going through tubing‬ ‭ uestion:‬‭Central venous access devices provide access‬‭for a variety of IV fluids, medications,‬ Q ‭blood products, and TPN solutions and allow a means for hemodynamic monitoring and blood‬ ‭sampling.‬ ‭a.‬ ‭True‬ ‭b.‬ ‭False‬ ‭Blood Sampling from Central Venous (Vascular) Access Devices‬ 1‭ .‬ ‭2.‬ ‭3.‬ ‭4.‬ ‭5.‬ ‭6.‬ ‭7.‬ ‭8.‬ ‭9.‬ ‭ ote site condition and appearance (erythema, warmth, swelling, tenderness, discharge)‬ N ‭Disconnect IV tubing from access port‬ ‭Clean access port and inject cap with antiseptic‬ ‭Allow to dry‬ ‭Connect 10 mL saline filled syringe‬ ‭Withdraw blood until it reaches the syringe tip, but do not let it enter the syringe‬ ‭Flush the line with saline in a 10 mL syringe‬ ‭Aspirate and withdraw blood using the same syringe‬ ‭(CONTINUE)‬ ‭Blood Transfusion‬ ‭●‬ ‭A procedure in which a patient receives a blood product through an IV line‬ ‭Autologous‬ ‭●‬ I‭ f surgery is scheduled months in advance, patients can donate their own blood and have‬ ‭it stored‬ ‭●‬ ‭4-6 prior to surgery‬ ‭Blood Types‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ I‭ nherited trait determined by antigens and antibodies int he blood‬ ‭Antigen:‬‭Substance causing antibody formation‬ ‭Antibody:‬‭Protein responding to antigens‬ ‭Agglutinin:‬‭Antibody causing clumping of antigens‬ ‭ABO Blood Groups‬ ‭●‬ ‭Type A: A antigens, anti-B agglutinins‬ ‭●‬ ‭Type B: B antigens, anti-A agglutinins‬ ‭●‬ ‭Type AB: A & B antigens, no agglutinins (universal recipient)‬ ‭●‬ ‭Type O: No A or B antigens, anti-A & anti-B agglutinins (universal donor)‬ ‭Rh Factor (+ or -)‬ ‭●‬ ‭Rh-positive: D antigen present‬ ‭●‬ ‭Rh-negative: D antigen absent‬ ‭●‬ ‭Rh-negative must receive Rh-negative blood to avoid reactions‬ ‭Importance of Blood Typing‬ ‭●‬ ‭Prevents transfusion reactions‬ ‭●‬ ‭Ensures compatibility between donor and recipient blood types‬ ‭Cross-Matching‬ ‭●‬ ‭Compares donor and recipient blood samples to ensure compatibility‬ ‭●‬ ‭Prevents dangerous reactions like agglutination or hemolysis of blood cells‬ ‭●‬ ‭A mismatch can result in severe consequences, including death‬ ‭Question:‬‭A person with blood type AB can give blood‬‭to a person with blood type A, B, or O.‬ ‭a.‬ ‭True‬ ‭b.‬ ‭False‬ ‭Blood Products‬ ‭Whole Blood‬ ‭●‬ ‭Replaces blood volume‬ ‭●‬ ‭Used when there has been significant blood loss (i.e. trauma or surgery)‬ ‭Packed Red Blood Cells (PRBCs)‬ ‭●‬ ‭Increases the oxygen carrying capacity of blood‬ ‭●‬ ‭Used when there has been significant blood loss, especially in patients with anemia‬ ‭Fresh Frozen Plasma (FFP)‬ ‭●‬ ‭Provides clotting factors, albumin, and immunoglobulins‬ ‭●‬ ‭Used in patients who have abnormal coagulation tests, are actively bleeding, or are at risk‬ ‭of heavy bleeding‬ ‭Platelet Concentrates‬ ‭●‬ ‭Replaces platelets‬ ‭●‬ ‭Use in patients with bleeding disorders or platelet deficiency (i.e. hemophilia or‬ ‭leukemia)‬ ‭Administering Blood‬ ‭‬ C ● ‭ arefully watch the patient, especially for the first 15 minutes‬ ‭●‬ ‭Check vital signs (baseline); 15-minute then hour intervals‬ ‭●‬ ‭Flow rate‬ ‭○‬ ‭Whole blood: 450-500 mL/unit, up to 4 mL/min‬ ‭○‬ ‭PRBCs: 300 mL/unit, 2 mL/min, no longer than 4 hours‬ ‭○‬ ‭FFP: 200 mL/unit, platelet (50 mL/unit) - 10 mL/min‬ ‭●‬ ‭Follow-up blood test‬ ‭Transfusion Reactions‬ ‭Overall Nursing Activity‬ ‭‬ D ● ‭ iscontinue immediately‬ ‭●‬ ‭Monitor V/S‬ ‭●‬ ‭Notify primary care provider immediately‬ ‭Febrile Reaction‬ ‭‬ F ● ‭ ever develops during infusion‬ ‭●‬ ‭S/S: Fever/chills, headache, malaise‬ ‭●‬ ‭Nursing activity:‬ ‭○‬ ‭Give antipyretics as ordered‬ ‭○‬ ‭KVO with a normal saline infusion‬ ‭Hemolytic Reactions‬ ‭ ‬ I‭ ncompatibility of blood product‬ ● ‭●‬ ‭Destruction of donor’s RBCs‬ ‭●‬ ‭S/S: Immediate onset of costovertebral angle pain, facial flushing, fever, chills, headache,‬ ‭shock‬ ‭●‬ ‭Nursing activity:‬ ‭○‬ ‭KVO with normal saline infusion‬ ‭○‬ ‭Treat shock if present‬ ‭○‬ ‭Obtain blood samples and first voided urine‬ ‭○‬ ‭Send unit, tubing, and filtering to lab‬ ‭Allergic Reaction‬ ‭‬ A ● ‭ llergy to transfused blood‬ ‭●‬ ‭S/S: Hives, itching, anaphylaxis‬ ‭●‬ ‭Nursing activity: Administer antihistamine as necessary‬ ‭Circulatory Overload‬ ‭‬ T ● ‭ oo much blood administered, causing excess fluid in the circulatory system‬ ‭●‬ ‭S/S: Dyspnea, dry cough, crackles, tachycardia, hypertension, pulmonary edema,‬ ‭distended neck veins‬ ‭●‬ ‭Nursing activity:‬ ‭○‬ ‭Administer diuretics/oxygen as orders‬ ‭○‬ ‭Keep patient upright‬ ‭Transfusion-Related Acute Lung Injury (TRALI)‬ ‭‬ E ● ‭ dema in the lungs due to an autoimmune reaction to the blood transfusion‬ ‭●‬ ‭Causes hypoxemia; lack of oxygenation due to alveolar tissue impairment‬ ‭●‬ ‭S/S: Onset within 6 hours; dyspnea, hypoxemia, hypotension, fever, chills, cyanosis,‬ ‭fainting, tachypnea, LOC‬ ‭●‬ ‭Nursing activity:‬ ‭○‬ ‭Monitor fluid balance‬ ‭○‬ ‭Support airway; supplemental oxygen‬ ‭Bacterial‬ ‭‬ B ● ‭ acteria present in the blood‬ ‭●‬ ‭S/S: Fever, hypertension, abdominal pain, flushed skin‬ ‭●‬ ‭Nursing activity: Administer antibiotics as prescribed‬ ‭Sepsis‬ ‭‬ A ● ‭ naphylaxis: Rash, hives, itching‬ ‭●‬ ‭S/S: High fever, dry and flushed skin, abdominal pain, oliguria, hypotension, confusion‬ ‭●‬ ‭Nursing activity:‬ ‭○‬ ‭KVO with a normal saline infusion‬ ‭○‬ ‭Administer IV fluids and antibiotics‬ ‭○‬ ‭Obtain blood specimen for culture‬ ‭○‬ ‭Return blood bag to lab‬ ‭Other Reactions‬ ‭ ‬ I‭ mmunosuppression‬ ● ‭●‬ ‭Transmission of infectious diseases‬