PPT_Chapter_45.ppt - Fluids Electrolytes and Total Parenteral Nutrition Chapter 45 Copyright \u00a9 2013 Wolters Kluwer Health | Lippincott Williams Wilkins

PPT_Chapter_45.ppt - Fluids Electrolytes and Total...

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Unformatted text preview: Fluids, Electrolytes, and Total Parenteral Nutrition Chapter 45 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Solutions Used in the Management of Body Fluids Blood plasma Plasma protein fractions Protein substrates Energy substrates Plasma proteins Electrolytes Miscellaneous replacement solutions Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions and Uses of Solutions Used in the Management of Body Fluids • Blood plasma – Liquid part of blood containing water, sugar, electrolytes, fats, gases, proteins, bile pigment, clotting factors – Human plasma is obtained from donated blood – Does not require typing and cross-matching – Administered IV – increases blood volume when severe hemorrhage has occurred and it is necessary to partially restore blood volume while waiting for whole blood to be typed and crossmatched – Also used in treating conditions when plasma alone has been lost, such as severe burns Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions and Uses of Solutions Used in the Management of Body Fluids Plasma protein fractions Include: human plasma protein fraction 5% and normal serum albumin 5% and 25% Critical in regulating the volume of circulating blood Used to treat hypovolemic shock that occurs as the result of burns, trauma, surgery, and infection, or in conditions in which shock is not currently present but likely to occur Also used to treat hypoproteinemia Blood type and cross-match is not needed Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions and Uses of Solutions Used in the Management of Body Fluids Protein substrates Amino acid preparations that act to promote the production of proteins Promote the production of proteins, enhance tissue repair and wound healing, and reduce the rate of protein breakdown Used in certain disease states, such as severe kidney and liver disease, and in total parenteral nutrition Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions and Uses of Solutions Used in the Management of Body Fluids • Energy substrates – Include dextrose solutions and fat emulsion – Solutions used to supply energy and fluid: dextrose in water, sodium chloride, alcohol in dextrose, IV fat emulsion – Dextrose is a carbohydrate – source of calories and fluid – Alcohol (in dextrose) – source of calories – Fat emulsion – source of calories and essential fatty acids • Used in the prevention and treatment of essential fatty acid deficiency • Also provides nonprotein calories for those receiving TPN Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions and Uses of Solutions Used in the Management of Body Fluids Plasma expanders Hetastarch, low-molecular-weight dextran, high-molecular-weight dextran Used to expand plasma volume when shock is caused by burns, hemorrhage, surgery, and other trauma Prophylaxis of venous thrombosis and thromboembolism Not a substitute for whole blood or plasma in the treatment of shock, but they are of value as emergency measures until those substances can be used Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions and Uses of Solutions Used in the Management of Body Fluids Intravenous replacement solutions Source of electrolytes and water for hydration Used to facilitate amino acid utilization and maintain electrolyte balance Dextrose and electrolyte solutions are used as a parenteral source of electrolytes, calories, or water for hydration Invert sugar-electrolyte solutions are used as a source of calories and hydration Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Solutions Used in the Management of Body Fluids Blood plasma Hemolytic transfusion reaction Patients with an immunoglobulin A deficiency may have an anaphylactic reaction to donor plasma as well Plasma protein fractions Rare Nausea, chills, fever, urticaria, hypotensive episodes Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Solutions Used in the Management of Body Fluids Protein substrates Nausea, fever, flushing of the skin, metabolic acidosis or alkalosis, decreased phosphorous and calcium blood levels Energy substrates Sepsis, thrombophlebitis Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Solutions Used in the Management of Body Fluids Plasma expanders Vomiting, mild temperature elevation, itching, allergic reactions Intravenous replacement solutions Generally well tolerated Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Solutions Used in the Management of Body Fluids Blood plasma Contraindications: hypersensitivity Precautions: pregnancy, lactation Interactions: none Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Solutions Used in the Management of Body Fluids Plasma protein fractions Contraindications: hypersensitivity, history of allergic reactions to albumin, severe anemia, cardiac failure Precautions: patients who are in shock or dehydrated, congestive cardiac failure, liver or kidney failure, pregnancy, lactation Interactions: none Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Solutions Used in the Management of Body Fluids Protein substrate Contraindications: hypersensitivity Precautions: pregnancy, lactation Interactions: none Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Solutions Used in the Management of Body Fluids Energy substrates Contraindications: hypersensitivity Dextrose solutions: diabetic coma with excessively high blood sugar, increased intracranial pressure, delirium tremens, hepatic coma, glucose-galactose malabsorption syndrome Alcohol-dextrose solutions: epilepsy, UTI, alcoholism, diabetic coma IV fat emulsions: conditions that interfere with normal fat metabolism, patients allergic to eggs Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Solutions Used in the Management of Body Fluids Energy substrates Precautions: Dextrose: patients receiving a corticosteroid or corticotropin IV fat emulsion: severe liver impairment, pulmonary disease, anemia, blood coagulation disorders, pregnancy, lactation Dextrose and alcohol dextrose solutions are incompatible with blood Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Solutions Used in the Management of Body Fluids Plasma expanders Contraindications: hypersensitivity, severe bleeding disorders, severe cardiac failure, renal failure with oliguria, anuria Precautions: renal disease, CHF, pulmonary edema, severe bleeding disorders, pregnancy, lactation Interactions: none Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Solutions Used in the Management of Body Fluids Intravenous replacement solutions Contraindications: hypersensitivity If too much solution is given, the patient may experience fluid overload or circulatory overload Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Solutions Used in the Management of Body Fluids Before use, vital signs should be taken Vital signs should be monitored during therapy Frequency depends on patient and solution Monitor for signs of fluid overload Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Solutions Used in the Management of Body Fluids Educate on the reason for and method of administration of an IV solution Educate on the importance of not touching the IV administration set or the equipment used to administer the IV fluids Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Electrolytes Electrically charged substances essential to the normal functioning of cells: Bicarbonate (HCO3) Calcium (Ca++) Magnesium (Mg++) Potassium (K+) Sodium (Na+) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions and Uses of Electrolytes Bicarbonate (HCO3) Acid-base balance in the body Used in IV treatment of metabolic acidosis secondary to shock, diabetic ketoacidosis, severe diarrhea, extracorporeal circulation of blood, severe kidney disease, or cardiac arrest Used orally as a gastric and urinary alkalinizer Also used in treating severe diarrhea accompanied by bicarbonate loss Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions and Uses of Electrolytes Calcium (Ca++) Necessary for the functioning of nerves and muscles Needed for clotting of blood Needed for building of bones and teeth Needed for other physiologic processes Treatment of hypocalcemia Given for CPR if epinephrine fails Used to reduce muscle cramping from insect bites or stings Dietary supplement when there is an increased need for calcium Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions and Uses of Electrolytes Magnesium (Mg++) Transmission of nerve impulses Activity of many enzyme reactions, such as carbohydrate metabolism Hypomagnesemia Controls seizures in obstetric patients Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions and Uses of Electrolytes Potassium (K+) Needed for transmission of impulses Needed for contraction of smooth, cardiac, and skeletal muscles Needed for other important physiologic processes Hypokalemia Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions and Uses of Electrolytes Sodium (Na+) Essential for maintenance of normal heart action and in osmotic pressure in body cells Normal saline contains 0.9% sodium, and half-normal saline contains 0.45% sodium Available with dextrose also Used cautiously when water retention is a problem Used to treat hyponatremia Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Electrolytes Bicarbonate (HCO3) Oral: nausea, vomiting Prolonged use orally or excessive doses intravenously may result in systemic alkalosis Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Electrolytes • Calcium (Ca) – IV: irritation of the vein, tingling, metallic or chalky taste, “heat waves” – Rapid IV: bradycardia, vasodilation, decreased blood pressure, cardiac arrhythmias, cardiac arrest – Oral: GI disturbances – Peripheral vasodilation, temporary decline in blood pressure, local burning Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Electrolytes Magnesium (Mg) Rare Overdose: flushing, sweating, hypotension, depressed reflexes, muscle weakness, circulatory collapse Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Electrolytes Potassium (K) Oral and IV: nausea, vomiting, diarrhea, abdominal pain, phlebitis Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Electrolytes Sodium (Na) No adverse effects unless an overdose Excessive oral use: nausea, vomiting Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Electrolytes Bicarbonate (HCO3) Contraindications: patients losing chloride by continuous GI suction or vomiting; patients with metabolic or respiratory alkalosis; hypocalcemia; renal failure; severe abdominal pain of unknown cause; sodium-restricted diets Precautions: CHF, renal impairment, glucocorticoid therapy, pregnancy Interactions: ketoconazole, quinidine, flecainide, sympathomimetics, fluoroquinolones, lithium, methotrexate, chlorpropamide, salicylates, tetracyclines, enteric-coated drugs Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Electrolytes Calcium (Ca) Contraindications: hypercalcemia, ventricular fibrillation, patients taking digitalis Precautions: cardiac disease Interactions: thiazide diuretics, atenolol, digitalis, verapamil, spinach, cereal Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Electrolytes Magnesium (Mg) Contraindications: patients with heart block, myocardial damage, women with pregnancy-induced hypertension during the 2 hours before delivery, renal impairment, marked myocardial disease, coma Precautions: renal function impairment Interactions: neuromuscular blocking agents Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Electrolytes Potassium (K) Contraindications: patients at risk for experiencing hyperkalemia, anuria, severe hemolytic reactions, untreated Addison disease, acute dehydration, heat cramps, hyperkalemia Precautions: renal impairment, adrenal insufficiency, heart disease, metabolic acidosis, prolonged or severe diarrhea Interactions: ACE inhibitor, potassium-sparing diuretic, salt substitute, digitalis Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Electrolytes Sodium (Na) Contraindications: hypernatremia, fluid retention; administration of sodium or chloride could be detrimental Precautions: surgical patients, those with circulatory insufficiency, hypoproteinemia, urinary tract obstruction, CHF, edema, renal impairment, pregnancy Interactions: none Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Electrolytes • Bicarbonate – Observe for signs of clinical improvements – Monitor vital signs frequently – Oral – take with a full glass of water • Calcium – Monitor vital signs until patient’s condition stabilizes – After administration, observe for hypercalcemia Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Electrolytes Potassium Observe for signs of hyperkalemia Monitor for signs of hypokalemia Magnesium If for convulsions or severe hypomagnesemia, patient requires constant observation Monitor vital signs Observe for signs of hypermagnesemia IM: undiluted and in a large muscle mass Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Electrolytes Sodium Observe during and after administration for signs of hypernatremia Observe for signs of pulmonary edema if receiving 3% or 5% sodium chloride Potassium May cause GI distress Take immediately after meals and with food and a full glass of water Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Electrolytes • Educate on how much and when to take the drug • Periodic laboratory and diagnostic tests my be ordered • Keep all appointments • Bicarbonate – warn against overuse • Sodium – excessive use can result in a serious electrolyte imbalance Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Electrolytes Calcium Do not exceed prescribed dose Notify health care provider if experience: nausea, vomiting, anorexia, constipation, abdominal pain, dry mouth, thirst, polyuria Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Electrolytes Potassium Take exactly as prescribed Do not increase, decrease, or omit doses Take immediately after meals or with food and a full glass of water Avoid use of OTCs Avoid use of salt substitutes Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Electrolytes Potassium Coated tablets: do not crush or chew, swallow whole Effervescent tablets: put in 4–8 oz of cold water or juice, wait until fizzing stops, drink over 5–10 minutes Liquid or powder: add to 4–8 oz of cold water or juice, sip slowly over 5–10 minutes Notify health care provider if: tingling of hands or feet, feeling of heaviness in legs, vomiting, nausea, abdominal pain, black stools Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family About Electrolytes Magnesium Do not take orally if you are experiencing abdominal pain, nausea, or vomiting Discontinue if experience diarrhea and abdominal cramping Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Total Parenteral Nutrition • Needed until normal eating can be resumed • Used to prevent nitrogen and weight loss • Used to treat negative nitrogen balance • Dose depends on patient’s condition Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Total Parenteral Nutrition Used when: The oral, gastrostomy, or jejunostomy route cannot or should not be used GI absorption of protein is impaired by obstruction Inflammatory disease or antineoplastic therapy prevents normal GI functioning Bowel rest is needed Metabolic requirements for protein are significantly increased Morbidity and mortality may be reduced by replacing amino acids lost from tissue breakdown Tube feeding alone cannot provide adequate nutrition Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Total Parenteral Nutrition • May be administered: – Peripheral vein • Patients requiring TPN for relatively short periods of time • Used when the patient’s caloric needs are minimal and can be partially met by normal means • Prevents protein catabolism in patients who have adequate body fat and no clinically significant protein malnutrition Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Total Parenteral Nutrition May be administered: Central venous catheter Promote protein synthesis in those who are severely hypercatabolic, are severely depleted of nutrients, or require long-term parenteral nutrition Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Total Parenteral Nutrition Contains: Amino acids Dextrose IV fat emulsions Vitamins Trace minerals Electrolytes Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Total Parenteral Nutrition • Daily dose depends on patient’s daily protein requirement, metabolic state, and clinical responses • Rate of administration is slowly reduced or the concentration of dextrose is gradually decreased to prevent a rebound hypoglycemic reaction Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ...
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