electrolyte imbalance.ppt

Intravenous Fluids

Management of clients with Fluid and Electrolyte Disturbances

Advantage• Preferred route for

administering fluids, electrolytes and drugs in emergency

Disadvantage• Drug and solution

incompatibility• Adverse reactions• Infections• complicstion


Crystalloids• Solutions with small

molecules that flow easily from the bloodstream into the cells and tissues

• Isotonic• Hypotonic• hypertonic

Colloids• Act as plasma expanders• Always hypertonic; pulls

fluid from cells into the bloodstream

• Requires close monitoring for signs and symptoms of hypervolemia

• Albumin• Plasma protein fraction• Dextran


Types of IVF according to tonicity

• Isotonic solutions• Hypotonic solutions• Hypertonic Solutions


Isotonic solutions

• Osmolality: 250-300 mOsm/kg• Have a concentration of dissolved particles or

tonicity equal to the intracellular fluid.• Osmotic pressure is therefore the same inside

and outside the cells, so they neither shrink nor swell with fluid movement.

• Eg. D5W, PNSS, PLR


Intravenous Fluids: IsotonicSolution Uses Special Considerations

D5W Fluid lossdehydration

- Solution is isotonic initially; becomes hypotonic when dextrose is metabolized- Don’t use for resuscitation- Use cautiously in renal or cardiac disease- doesn’t provide enough daily calories for prolonged use

PNSS Shock, Hyponatremia, Resuscitation, BT, DKA, Hypercalcemia, Metabolic Alkalosis

- don’t use in patient’s with heart failure, edema, hypernatremia

LR Dehydration, burn, Lower GIT fluid loss, acute blood loss, hypovolemia d/t 3rd space shifting, mild metabolic acidosis, salicylate overdose

- No magnesium- Don’t use in patients with renal failure or with liver disease


Hypotonic Solutions

• Osmolality: < 250 mOsm/kg• Have tonicity less than the ICF, so osmotic

pressure draws water into the cells from the ECF

• It makes the cell swell• Contraindicated: Increase ICP, Liver Dse, burn,

trauma• Ex. Half-normal saline, 0.33% NaCL, D2.5W


Intravenous Fluids: Hypotonic

Solution Uses Special Considerations.45% NaCL(half-

normal saline

solution)

Water replacementDKA after initial NSS and before dextrose solutionHypertonic dehydrationNa and CL depletionGastric fluid loss from vomiting of NGT lavage

-Use cautiously; can cause Cardiovascular collapse or increase ICP-Don’t use in patients with liver disease, trauma or burns


Hypertonic Solution

• Osmolality: >300mOsm/kg• Tonicity is greater than that of ICF, so osmotic

pressure is unequal inside and outside the cell• It draws fluid from the intracellular space

causing the cells to shrink and extracellular space to expand.

• Contraindication/Caution: DKA, cardiac or renal disease


Intravenous Fluids: HypertonicSolution Uses Special ConsiderationsD5NSS Hypotonic dehydration

Temporary treatment of circulatory insufficiency and shock if plasma expanders aren’t available

- Don’t use in patients with cardiac or renal disease

D10W Water replacementConditions in which some nutrition with glucose is required

Monitor serum glucose


Delivery methods• Potential IV site:

metacarpal, cephalic, basilic, median cubital, greater saphenous veins

• Choose the right site• Needle size matters:

the higher the size, the smaller the diameter of the needle


Complications of IV therapy

• Infiltration• Infection• Phlebitis• Thrombophlebitis• extravasation


Infiltration

• Fluid leaks from the vein into surrounding tissue• Occurs when the access device dislodges from the vein

coolness at the site pain swelling leaking lack of blood return

• Management: Stop the infusionremove IV catheterelevate the extremityapply warm compress


Go Small to prevent infiltration

• Use the smallest catheter• Avoid placement in joint areas• Anchor the catheter in place


Infection

• The primary barrier to infection is puncturedPurulent drainage at the site tendernessErythemaWarmth or hardness on palpationSystemic: fever, chills, inc. WBC


Monitoring vital signs is vital

• Check vital signs and notify the physician• Swab the site for culture• Remove the catheter as ordered• Maintain aseptic technique


Phlebitis and thrombophlebitis

• Phlebitis is the inflammation of veins• Thrombophlebitis is an irritation of the vein

with the formation of a clot and usually more painful than phlebitis

painrednessSwelling or induration at the siteRed line streaking along the veinFeverSluggish flow of the solution


Prevention begins with big veins

• Remove the IV• Monitor vital signs• Notify the physician• Apply warm soaks at the site • Choose large veins and change the catheter

every 72 hours to prevent this complication


Extravasation

• Similar to infiltration• This results when medications (dopamine,

calcium solutions, and chemo drugs) seep through veins and produce blistering and eventually necrosis.

Initially: discomfort and burning sensation at the siteSkin tightnessblanchingLack of blood return


Review the policy

• Stop the infusions• Notify the doctor• Apply ice early and warm soaks later• Elevate the extremities• Assess the circulation and nerve function of

the limb• When giving drugs that may extravasate,

know the hospital’s policyManagement of clients with Fluid and

Electrolyte Disturbances

Severed catheter• Occurs when a piece of catheter becomes dislodged

and is set free in the veinPain at the fragment siteDecreased BPcyanosisLoss of consciousnessWeak and rapid pulse

• ManagementApply tourniquet above the site of painNotify the physician immediatelyMonitor the patient Avoid reinserting a needle through its plastic catheter once the

needle has been withdrawnManagement of clients with Fluid and


Allergic reactionRed streak extending up the armRash itchingWatery eyes and nosewheezing

• ManagementStopping the IVF immediatelyNotify the physician immediatelyMonitor the patient Giving oxygen and medication as ordered


Air embolism• Occurs when air enters the vein

decrease in blood pressure increase in PRrespiratory distress increase ICPLoss of consciousness

• ManagementNotify the physician and clamp the IVPlace the patient on his left side and lower his headMonitor VS and administer oxygenTo avoid serious complication, prime all tubing completely,

and tighten all connections securelyManagement of clients with Fluid and


Speed shock• Occurs when IV solutions or medications are given

too rapidlyFacial flushingIrregular pulseSevere headacheDecrease blood pressureLoss of consciousness and cardiac arrest

• Managementclamp the IV and Notify the physician immediatelyMonitor VS and administer oxygen administer medication as orderedInfusion control device can prevent this complication


Fluid overload• Happens gradually or suddenly, depending on how well the

patient’s circulatory system can accommodate the fluid. Neck vein distentionPuffy eyelidsEdemaWeigh gainIncreased BPIncreased RRSOB, cough and crackles

• ManagementSlow the IV rate, notify the physician and monitor VSKeep the patient warm, keep the head of bed elevatedGive oxygen and other medication (diuretic) as order


Blood Products and

Blood TransfusionManagement of clients with Fluid and


Blood Transfusion

• Restores blood volume, correct deficiencies in the blood’s oxygen carrying capacity and its coagulation components, or replace WBC in patients who need them

• Nurses need to be knowledgeable about the various blood products available to safely transfuse blood to their patients


Compatibility

• Blood contains various antigens that affect how compatible one person’s blood is with another’s.

• The antigen include: ABO blood group, Rh factor and Human Leukocyte Antigen(HLA) blood group


ABOs of typing blood

• Identifies two antigens on RBC--- A and B– A person has both A and B antigens (type AB)

only one antigen (type A or type B)or neither (type O) • A antigen has anti-B antibodies floating freely in the plasma• B antigen has anti A antibodies floating freely in the plasma

Type AB – universal recipients Type O – universal donors Ideally transfusion should be done using the

same type of blood as the patient


Blood-type compatibilityRecipient’s blood type

Compatible donor type

A A, OB B, O

AB A, B, AB, OO O


Rhesus (Rh) factor

• About 85% of US population in Rh-positive, which means possessing Rh antigen, an antigen found on the membrane of RBC

• Rh negative people may develop Rh antibody if exposed to Rh positive blood– 1st exposure: sensitization– 2nd exposure: fatal hemolytic reaction (can occur

during transfusion or pregnancy)


Fixing an Rh problem

• If an Rh negative patient is exposed to Rh-positive blood, an injection of Rh0(D) immune globulin can be given within 72 hours of exposure.

• Rh0(D) immune globulin inhibits antibody formation

• Common preparation include: RhoGAM


Human Leukocyte Antigen (HLA)

• Located on the surface of circulating platelets, WBC and most tissue cells

• Responsible for febrile reactions in patients receiving a transfusion that contains platelets from several donors

• In that instance antigen-antibody reaction causes platelet destruction

• As a result, patient becomes less responsive to platelet transfusion


Types of Blood products

• Fresh Whole blood»Used unless the patient has loss more

than 25% of total blood volume.»Used to treat hemorrhage, trauma, or

major burns» Should be avoided if fluid overload is

presentABO compatibility and Rh matching



• Packed RBC» Prepared by removing about 90% of the

plasma surrounding the cells and adding an anticoagulant preservative

» Helps in restoring or maintaining the oxygen carrying capacity of the blood in patients with anemic conditions or can correct blood losses during or after surgery

» ABO compatibility and Rh matching



• WBC»Rarely indicated; however they may be

used to treat gram-negative sepsis or progressive soft tissue infection that’s unresponsive to microbial.

HLA compatibility and Rh matching



• Fresh Frozen Plasma (FFP)» Prepared by separating the plasma from the

RBCs and freezing it within 6 hours of collection

» Used to treat hemorrhage, expand plasma volume, correct undetermined coagulation factor deficiencies, replace specific clotting factors and correct factor deficiencies resulting from liver disease

Rh matchingManagement of clients with Fluid and



• Cryoprecipitate (factor VIII)» Insoluble portion of plasma recovered from

FFP» Used to treat hypofibrigenemia, factor VIII

deficiency (antihemophilic factor), hemophilia A, DIC



• Albumin» Extracted in plasma and contains globulin

and other proteins» Used for patients who have acute liver

failure, burns, trauma or who have had surgery as well as for neonates with hemolytic disease when crystalloids prove ineffective



• Platelet» Used for patients who have platelet

dysfunction or thrombocytopeniaRh matching


Blood transfusion procedure

Before starting BT: Informed consent, explain the procedureCultural considerationVS (notify physician if febrile) If receiving other medication, it should not be mix with

blood productsDoctor’s order regarding BT to prevent errorsTriple check the patient’s identity (right transfusion at the right time)

If with previous transfusion


How to avoid BT errors

• Match the patient’s name, medical record numberm ABO, Rh status, blood bank identification numbers with the label on the blood bag

• Check expiration date• Have the other nurse verify the information• Sign the blood slip, filling the required data. The blood slip will

prove useful if the patient develops an adverse effect• Double-check the doctor’s order • Be sure that the blood was typed and cross-matched within

the last 48hoursManagement of clients with Fluid and


Blood transfusion procedureDuring BT: Maintain sterile technique Observe standard institutional policies and standard precautions Flush with NSS before and after infusing blood products Infuse blood products through at least an 18G or 20G IV catheter Transfuse blood using a Y-type IV administration set with filter and

infuse the blood over 2 to 4 hours When starting the transfusion, remain with the patient and

observe carefully for first 15 minutes Use a pressure bag or specialized infusion pump to administer

blood more rapidly, if needed


• When giving platelet concentrate, it should be transfused over 15 minutes

• Check platelet count 1 hour after the transfusion ends


Blood transfusion procedureAfter BT: Monitor patient’s status Watch for signs of fluid overload, especially in elderly patients Obtain laboratory test Document:

Patients identificationIdentification of blood products, including date of expirationVS before, during and after BTDate, time, type, amount and duration of transfusionAdverse reaction and actions takenPatient response, including laboratory resultsAssessment after transfusionPatient teaching


Blood transfusion reaction…


electrolyte imbalance.ppt

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