Unit 4 - LPN­C LPN­C Unit Four Rationale for Intravenous...

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Unformatted text preview: LPN­C LPN­C Unit Four Rationale for Intravenous Therapy Maintenance What is the Purpose of Intravenous Therapy? Restoration of previous losses Administration of medication ◦ Water ◦ Glucose ◦ Protein ◦ Vitamins ◦ Electrolytes ◦ pH Replacement of present losses 2 Water is necessary for adequate kidney function – Normal Intake Normal Output Oral liquids 1300mL Urine 1500mL Water in food 1000mL Stool 200mL Metabolism 300mL Lungs 300mL Total 2600mL Skin 600mL Total 2600mL 3 Water Converted to glycogen by the liver Glucose Has 4 main uses in parenteral therapy Approximately 100 – 150g of glucose ◦ Improves hepatic function ◦ Supplies the necessary calories for energy ◦ Spares body protein ◦ Minimizes ketosis is needed daily to minimize protein catabolism 1 liter of 5% dextrose in water supplies 50g of glucose Dextrose in water is available in 2.5%, 5%, 10%, 20%, and 30% 4 Dextrose concentrations higher than Glucose (cont’d) 10% must be given through a central vein ◦ The exception is 50% dextrose slow IV push at a rate of 3mL/min through a peripheral vein for emergency treatment of hypoglycemia Amino acids are the building blocks of Protein the body Available in concentrations of 3.5 – ◦ Tissue growth and repair ◦ Would healing 5 Daily requirements = 1g protein/kg Protein (cont’d) body weight Gluconeogenesis = conversion of ◦ Amount increases as stress to the body increases protein to glucose to meet energy requirements ◦ Occurs during starvation, stress, or infection ◦ Uses large amount of energy ◦ Body will use protein for energy if there are inadequate glucose stores 6 Vitamins B and C are most frequently Vitamins used ◦ Vitamin B is needed for the metabolism of carbohydrates and maintenance of GI function ◦ Vitamin C promotes wound healing Correction of electrolyte imbalances is Electrolytes important in preventing serious complications Important in parenteral therapy ◦ Potassium, sodium, chloride, magnesium, 7 Potassium Electrolytes (cont’d) ◦ Adequate replacement therapy = 20mEq/L ◦ Patients who need potassium replacement – Stress from tissue injury Wound infection Gastric or bowel surgery Prolonged gastric suction ◦ Assess renal function prior to potassium replacement Excreted through the urine Intoxication can occur rapidly and with no symptoms ◦ Slow rate of infusion no more than 20mEq/L per hour via peripheral line no more than 40mEq/L per hour via central line 8 Potassium (cont’d) ­­ Electrolytes (cont’d) ◦ Infiltration of potassium is extremely irritating to the tissue Can cause necrosis Imperative to use extravasation protocol Hyaluronidase (Wydase) used to be used as an antidote for potassium extravasation, but has been discontinued In the case of infiltration, discontinue the infusion, apply cool compresses, and elevate the extremity by 4 inches Most IV solutions are acidic pH ◦ Allows a longer shelf life ◦ The more acidic a solution, the more irritating to the vein 9 Peripheral venous delivery of Parenteral Nutrition parenteral nutrition (PPN) ◦ Glucose concentration is not to exceed 10% ◦ Usually utilized for 3 – 7 days ◦ Assess for metabolic abnormalities Hyperglycemia Most common metabolic abnormality in PPN Rapid administration of fluid Increased levels of stress hormones Hypoglycemia can occur if infusion is discontinued abruptly Hypokalemia Insulin­related shift of potassium from the extracellular compartment to the intracellular compartment 10 More vulnerable to fluid volume deficit Fluid Balance in Infants and Children Kidneys are immature up to 2 years of age Body surface area in infants is larger ◦ Cannot conserve or excrete water or sodium in response to imbalances as efficiently as adults ◦ Lose more fluid through the skin than in adults per size Infants have a higher metabolism rate which requires more water per size ◦ Produce more heat than adults ◦ Larger amount of metabolic waste to 11 Fluid Balance/Infants/Children (cont’d) Fevers are higher and last longer in acute illness Symptoms of fluid imbalance ◦ Increases fluid loss Nursing assessment ◦ Decreased appetite ◦ Less active ◦ More irritable ◦ Flaccid appearance ◦ Diarrhea, vomiting ◦ Decrease in voiding ◦ Assess concentration of urine 12 Fluid Balance/Infants/Children (cont’d) Nursing assessment (cont’d) ­­ ◦ Weigh diapers ◦ Monitor for diarrhea Common cause of isotonic dehydration Formula containing an inappropriately high amount of solute can cause diarrhea that leads to hypertonic dehydration Proportionate loss of water and electrolytes ◦ Monitor for weight changes Physician’s records Parent/family/caregiver report Greater loss of water than electrolytes Record weight before onset of illness Weight loss resulting from fluid volume deficit 13 is more rapid than with loss of body mass Nursing assessment (cont’d) – Fluid Balance/Infants/Children (cont’d) Blood pressure is not always reliable because elasticity of the blood vessels in children keeps blood pressure stable initially ◦ Monitor vital signs Tissue turgor ◦ Skin remains slightly raised for a few seconds with fluid volume deficit ◦ Skin turgor begins to decrease after 3­5% body weight is lost as fluid ◦ Obese infants/children have deceptive skin turgor Normal in appearance in spite of fluid volume 14 At risk for fluid volume deficit due to Fluid Balance in the Elderly normal aging changes ◦ 6% reduction of total body water ◦ Decrease in ratio of intracellular fluid to ECF ◦ Loss of 30­50% glomeruli by the age of 70 ◦ Decrease in glucose tolerance ◦ Decreased sensation of thirst ◦ Decreased skin elasticity Decrease in glomerular filtration rate Decreased ability to concentrate urine Decreased secretion of aldosterone Decrease in the response of the distal tubule to ADH 15 Normal aging changes (cont’d) ­­ Fluid Balance in the Elderly (cont’d) ◦ Diminished capillary bed Less effective cooling of body temperature Increased risk for orthostatic hypotension Increased risk for falls ◦ Decreased cardiac output Typical assessment findings ◦ Decreased elasticity of arteries ◦ Immediately assess fluid status with any changes in mental status ◦ Dehydration frequently seen ◦ Normal body temperature lower (97°F) ◦ Mucus membranes less moist ◦ Positional changes in blood pressure 16 Typical assessment findings (cont’d) – Special problems in the elderly Fluid Balance in the Elderly (cont’d) ◦ Most accurate assessment of skin turgor is over the sternum ◦ Hypernatremia ◦ Reduced motility of GI tract ◦ Heat stroke Laxative dependency Common problem in LTC facilities Immobility Unable to express thirst Elderly more susceptible Decreased efficacy of sweat glands Normal temperature decreases with age Temperature of 99°F would be high for the body 17 Special problems (cont’d) ­­ Fluid Balance in the Elderly (cont’d) ◦ Radiocontrast agents (IVP) High in sodium Difficulty excreting due to ↓ glomerular filtration rate Administration of adequate IV fluids before surgery Minimum urine output should be 50mL/hour High risk for hypothermia in the operating room Improves renal blood flow and renal function ◦ Preoperative concerns ◦ Diminished respiratory function interferes with elimination of carbon dioxide Leads to respiratory acidosis 18 Cool fluids, cool environment, etc. Special problems (cont’d) ­­ Bowel cleansing NPO status Fluid Balance in the Elderly (cont’d) ◦ Preparation for diagnostic tests Difficulty chewing or swallowing Malnutrition/starvation Diet and Lifestyle Factors Affecting Fluid Balance ◦ Inadequate food/fluid intake Excessive alcohol consumption ◦ Low protein intake; altered fluid volume status ◦ Liver damage leading to fluid/electrolyte 19 Environmental Factors & Fluid Balance Vigorous exercise increases metabolism, ventilation, sweating ◦ Increases fluid demand ◦ Potential lack of fluid intake Heat injuries Diuretics = excessive fluid loss Medications Altering Fluid Balance ◦ Exposure to hot, humid environments increases sweat production to as much as 2L/hour ◦ Body fluid weight loss >7% is associated with failure of body cooling mechanisms Chemotherapy = nausea/vomiting, 20 Fluid Needs for Those with Acute Illness Surgery can result in blood and fluid loss Gastroenteritis causes nausea/vomiting and diarrhea Nasogastric suctioning leads to fluid and electrolyte losses Brain injury from stroke, trauma, or tumor ◦ Causes cerebral edema, which may put pressure on the hypothalamus and/or pituitary ◦ Alters ADH SIADH Diabetes insipidus 21 Factors affecting fluid loss ­­ Burns ◦ Surface area Diagnostic findings – ◦ Extent, depth, and cause of the burn ◦ Age of the client ◦ Pre­existing medical conditions The larger the burn, the greater the fluid loss ◦ WBC reflects immune function ◦ Hgb/HCT increases due to fluid loss ◦ Glucose increases due to stress response ◦ Sodium decreases (trapped in third spaces) 22 Third space fluid shifts ­­ Burns (cont’d) ◦ Phase I → plasma to interstitial space Occurs rapidly (before the end of the 1st hour) Plasma leaks out through damaged capillaries at the burn area Edema forms Hypovolemia occurs (may lead to acute tubular necrosis) Low urine output Hyperkalemia Decreased renal perfusion Fluid accumulation phase occurs during the first 36 to 48 hours Capillaries have recovered by the end of this time 23 Third space fluid shifts (cont’d) ­­ Burns (cont’d) ◦ Phase II → fluid remobilization Nursing assessment – Begins approximately 48 hours after burn occurs Edema at burn site resolving Hypervolemia due to fluid shifting back into the intravascular compartment Metabolic acidosis due to accumulation of acids released from the injured tissue Respiratory acidosis due to inhalation injury that interferes with gas exchange ◦ Rule of Nines ◦ Lund­Browder Chart 24 Relative Percentage of Body Surface Area Affected by Growth Age in years 0 1 5 10 15 Adult A­head (back or front) 9½ 8½ 6½ 5½ 4½ 3½ B­1 thigh (back or front) 2¾ 3¼ 4 4¼ 4½ 4¾ C­1 leg (back or front) 2½ 2½ 2¾ 3 3¼ 3½ LUND­BROWDER CHART Treatment ­­ Burns (cont’d) ◦ Aggressive fluid replacement is necessary to prevent complications ◦ Use large bore IV in a peripheral vein in an area that is unaffected by burn injury 2nd choice = central line in an unaffected area 3rd choice = peripheral line in an affected area Last choice = central line in an affected area Need to induce urine output at 1cc/kg/hour ◦ Monitor for IV­related sepsis ◦ Foley catheter placement ◦ Early burn wound excision ◦ Timely initiation of enteral nutrition 27 Liver disease decreases production of Fluid Needs for Those with Chronic Illness albumin, which affects the ability to maintain vascular volume Renal disease limits the ability to regulate fluid or electrolytes via urine output Diabetes increases the risk for hyperglycemia and hypertonic dehydration Cancer treatment (chemotherapy) induces nausea/vomiting with fluid loss and decreased intake 28 Occurs in 2 – 5% of people with Type I Diabetic Ketoacidosis (DKA) Diabetes Mellitus Most often begins with an infection Can also be seen in Type II Diabetes Mellitus if illness or stress exceeds the ability of the pancreas to secrete adequate insulin Death occurs in 1 – 10% of cases even with appropriate treatment Onset is sudden (less than 24 hours) Diagnostic criteria includes hyperglycemia, hyperketonemia, and 29 Pathophysiology ­­ Body is unable to utilize carbohydrates DKA (cont’d) Results in ketones in the blood and ◦ Not enough insulin to transport glucose into the cells ◦ Body resorts to utilizing fats for energy urine Etiology – Inadequate medication/insulin Infection ◦ Leads to acidosis 30 Clinical manifestations ­­ Rapid, weak pulse Kussmaul’s respirations “Fruity” breath Nausea/vomiting, abdominal pain Dehydration Polyuria, polydipsia Normal/low temperature in the presence of infection Weight loss Dry skin Sunken eyes, soft eyeballs Lethargy, coma DKA (cont’d) 31 Lab findings – Serum glucose = >300mg/dL Serum ketones = positive Urine ketones = positive Serum pH = <7.35 Serum HCO3 = <15mEq/L Serum potassium = ↑ with acidosis, ↓ with dehydration BUN = >20mg/dL due to dehydration Creatinine + >1.5mg/dL due to dehydration 32 DKA (cont’d) Emergency management – Establish a patent airway Administer oxygen and NaHCO3 if ↓ pH Place IV with large bore catheter Administer NS per IV DKA (cont’d) IV fluid changed to D5 ½ NS when ◦ 1L/hour for first 2­3 hours to stabilize blood pressure and ensure adequate urine output serum glucose reaches 250mg/dL Urine output will decrease as osmotic 33 Ongoing monitoring – Monitor blood glucose Assess for hypokalemia DKA (cont’d) Will need to decrease infusion rate ◦ Potassium will reenter the cell with insulin administration when blood glucose is ≤300mg/dL Anticipate order of D5W when blood glucose level is 250mg/dL Assess for signs and symptoms of ◦ Reduces risk of hypoglycemia hypoglycemia ◦ Anxiety, behavior changes, confusion, headache, slurred speech ◦ Blurred vision, hunger, cold sweats, 34 Hyperglycemic­Hyperosmolar Nonketotic Syndrome (HHNS) HHNS is a medical emergency with a high mortality rate Hyperosmolar state caused by hyperglycemia Exhibits no ketosis ◦ Blood glucose = 800mg/dL ◦ Serum osmolarity = possibly >350mOsm/L May be seen in Type II Diabetes Mellitus Often related to impaired thirst 35 Rapid progression HHNS (cont’d) Clinical manifestations – ◦ Hours to days Treatment – ◦ Polyuria, polydipsia, dehydration, aphasia ◦ Altered mental status (lethargy → coma) ◦ Postural hypotension, tachycardia ◦ Seizures, tremors, nystagmus, hyperreflexia ◦ Management is similar to DKA except HHNS requires greater fluid replacement as patient can have a 9­12L fluid deficit 3 ◦ Administer regular insulin at 0.1U/kg/hour 6 Treatment (cont’d) – HHNS (cont’d) ◦ Fluid resuscitation ◦ Support airway, breathing, circulation Administer 1­2L NS for 1st hour Follow with 1L/hour for the next several hours Hyperglycemia will decrease with fluid resuscitation May need to give low­dose insulin if patient is hyperkalemic, acidotic, or in renal failure 37 Onset Serum Glucose Serum Ketones Serum pH Serum HCO3 mEq/L Serum K Differences between Diabetic Ketoacidosis (DKA) and Hyperglycemic­Hyperosmolar Nonketotic Syndrome (HHNS) DKA HHNS Sudden Gradual >300 >800 Yes No <7.35 >7.4 <15 mEq/L >20 Normal Normal ↑ with acidosis ↓ with >350 mOsm/L ↑ 38 dehydration Serum Osmolarity Variable BUN ↑ ~ dehydration The stomach is acidic Gastrointestinal Disturbances Fluid volume deficit possible ◦ pH = 1.0 – 3.5 Monitor for hypokalemia ◦ Prolonged vomiting ◦ Gastric suction Monitor for hyponatremia due to ◦ Potassium is present in gastric juices prolonged loss of sodium ◦ Suctioning ◦ Nasogastric irrigation with plain water 39 Types of fluid volume deficit – Fluid Volume Deficit ◦ Isotonic fluid loss ◦ Hypertonic dehydration ◦ Third spacing Fluid and solute are lost equally Intracellular water is not disturbed Fluid loss is extracellular fluid Isotonic Fluid Loss ◦ Serum osmolarity remains normal ◦ Can quickly lead to shock ◦ Requires extracellular fluid replacement ◦ Emphasis is on increasing vascular 40 Causes – Isotonic Fluid Loss (cont’d) ◦ Hemorrhage ◦ Gastrointestinal losses Loss of fluid, electrolytes, proteins, and blood cells results in inadequate vascular volume Vomiting, NG suctioning, diarrhea, drainage from fistulas/tubes Profuse sweating causes water and sodium loss through the skin Damages skin capillary membranes Allows fluid, electrolytes, and proteins to escape into burned tissue area, leaving less ◦ Fever, environmental heat, diaphoresis ◦ Burns 41 Causes (cont’d) – Isotonic Fluid Loss (cont’d) ◦ Diuretics can cause excessive loss of fluid and electrolytes ◦ Third spacing Fluid moves from the vascular space into extracellular spaces Treatment – ◦ Expand extracellular volume with isotonic IV fluids ◦ Provide blood transfusion for hypovolemia caused by hemorrhage 42 Increases circulating blood volume Restores renal perfusion Treatment (cont’d) – Isotonic Fluid Loss (cont’d) ◦ Administer 1–2L bolus of isotonic fluid for adults ◦ Administer up to an additional 2–3L Infuse in 30 minutes or less ◦ Infuse 20–30 mL/kg bolus of isotonic fluid for infants/young children to improve urine output, heart rate, respiratory rate, and mental status Improves urine output, blood pressure, heart rate, and mental status 43 More water is lost than solute Hypertonic Dehydration ◦ Creates a solute excess Primarily sodium Solute can also be gained in excess of ◦ Results in fluid volume deficit Serum osmolarity becomes elevated ◦ Creates a similar imbalance ◦ Most common with sodium or glucose water ◦ Results in hypertonic extracellular fluid ◦ Pulls fluids into the vessels from the cells by osmosis ◦ Causes cells to shrink and become dehydrated 44 Causes – Inadequate fluid intake Hypertonic Dehydration (cont’d) Severe or prolonged isotonic fluid ◦ Inability to respond to thirst ◦ May occur due to age (infants or the elderly), immobility, nausea, anorexia, dysphagia, or being NPO without fluid replacement ◦ Extracellular fluid becomes hypertonic and draws water from the cells losses Compensatory mechanisms become exhausted Conservation of water via the kidneys depleted Results in cellular dehydration 45 Causes (cont’d) – Watery diarrhea Hypertonic Dehydration (cont’d) Diabetes insipidus ◦ Loss of more water than electrolytes ◦ Leads to massive, uncontrolled diuresis of dilute urine ◦ Usually caused by a brain injury As much as 30L/day Can quickly lead to shock and death ◦ Need to administer parenteral vasopressin ◦ In a fluid volume deficit related to diabetes insipidus, urine will be pale, dilute, and high in volume 46 Damages/puts pressure on the hypothalamus or pituitary gland Causes (cont’d) – Increased solute intake Hypertonic Dehydration (cont’d) ◦ Excessive salt, sugar, or protein intake without a proportional intake of water ◦ Increases plasma osmolarity ◦ Water is pulled from the cells, leading to cellular dehydration ◦ Results in osmotic diuresis, which makes cellular dehydration worse Dangerous for patients with heart or kidney problems Conditions that lead to hypertonic dehydration – Highly concentrated enteral or 47 Conditions that lead to hypertonic dehydration (cont’d) – Improperly prepared infant formulas that are too concentrated Hyperglycemia and/or diabetic ketoacidosis Increased sodium ingestion Hypertonic Dehydration (cont’d) ◦ Excessive glucose and ketones in the blood ◦ Ingestion of excessive amounts of seawater ◦ Taking salt water tablets Excessive use of osmotic diuretics 48 Clinical manifestations – Thirst Hypertonic Dehydration (cont’d) Concentrated urine ◦ Early sign of dehydration ◦ Unreliable in the elderly and the very young ◦ Dark in color ◦ High specific gravity (normal is 1.010 – 1.030) ◦ Normal output for adults is 30mL/hour ◦ When assessing mucus membranes, 49 Low urine volume Dry mucus membranes Clinical manifestations (cont’d) – Dry skin ◦ Decreased turgor ◦ Decreased elasticity ◦ Tenting Hypertonic Dehydration (cont’d) Tissues stick together from interstitial fluid loss Unreliable in the elderly due to decreased elastin Check infant skin over abdomen or inner thighs Test on sternum, forehead, inner thigh, top of hip instead of arms and legs Dry tongue with longitudinal furrows Decreased tearing with dry conjunctiva 50 Clinical manifestations (cont’d) – Sunken or depressed fontanel in infants less than 1 year Flat neck veins and poor peripheral vein filling Hypertonic Dehydration (cont’d) Tachypnea ◦ Jugular veins are nondistended even with the head of bed at <45 degrees ◦ When the hand is placed lower than the heart, the hand veins normally distend in 3 – 5 seconds 51 Clinical manifestations (cont’d) – Low grade fever Mental status changes Hypertonic Dehydration (cont’d) ◦ May be higher in severe dehydration ◦ Often the first sign noticed in the elderly ◦ Irritability, restlessness ◦ Drowsiness, lethargy ◦ Confusion ◦ Tachycardia (early sign in infants) ◦ Weak, thready pulse ◦ Cool extremities with delayed capillary Decreased cardiac output 52 Clinical manifestations (cont’d) – Postural hypotension when rising from lying to standing position Hypertonic Dehydration (cont’d) Frank hypotension ◦ Pulse increased by greater than 10­15 bpm ◦ Fall in systolic blood pressure by greater than 10­15 mmHg ◦ The greater the fall in blood pressure or rise in heart rate, the greater the fluid volume deficit ◦ Weakness, dizziness, light­headedness, syncope ◦ Exists even when lying down 53 Clinical manifestations (cont’d) – Acute weight loss ◦ 2% body weight loss ◦ 5% body weight loss Mild fluid deficit (thirst) 1 – 2 L fluid loss in an adult Hypertonic Dehydration (cont’d) ◦ 8% body weight loss Moderate fluid deficit Signs and symptoms of dehydration appear 3 – 5 L fluid loss in an adult Severe fluid deficit Frank hypotension 5 – 10 L fluid loss in an adult Fatal >10L fluid loss in an adult ◦ >15% body weight loss 54 Parenteral therapy – Hypovolemia and impending shock Hypertonic Dehydration (cont’d) ◦ Isotonic fluids administered for adequate circulation and renal perfusion ◦ Hypotonic solutions administered to correct cellular dehydration Hypervolemia Given slowly to prevent cerebral edema due to sensitivity of brain cells to hypotonicity ◦ Resulting from excessive sodium intake ◦ Administer a diuretic with hypotonic fluid to provide free water to cells while preventing vascular volume overload 56 Nursing interventions ­­ Monitor vital signs for changes in heart rate, blood pressure, and respiratory rate Assess mental status Hypertonic Dehydration (cont’d) Monitor urine output and ◦ Lack of improvement (or worsening) could indicate the infusion of hypotonic fluids is too rapid concentration Monitor IV rate Monitor I&O ◦ Watch for fluid volume overload 57 Lab findings – Hemoconcentration Hypertonic Dehydration (cont’d) High urine specific gravity (>1.030) ◦ Plasma becomes concentrated to the red blood cells and urea particles ◦ BUN would be high ◦ Kidneys conserve water while continuing to excrete solute ◦ In cases of diabetes insipidus, specific gravity would be low (<1.010) ◦ Elevated serum osmolality (>300mOsm/kg) ◦ Elevated serum potassium (>150mEq/L) 58 ◦ Elevated serum glucose (>120mg/dL) Increased plasma concentration Third spaces are extracellular body Third Spacing spaces where fluid can accumulate This accumulated fluid is useless to the body Common locations for third space ◦ Unavailable for use as reserve fluid ◦ Unable to transport nutrients fluid to accumulate – ◦ Tissue spaces (edema) ◦ Abdomen (ascites) ◦ Pleural spaces (pleural effusion) ◦ Pericardial space (pericardial effusion) 59 Causes – Injury or inflammation Third Spacing (cont’d) ◦ Increased capillary permeability allows fluid, electrolytes, and proteins to leak from the vessels Massive trauma Crush injuries Burns Sepsis Cancer Intestinal obstruction Abdominal surgery 60 Causes (cont’d) – Malnutrition or liver dysfunction Starvation Cirrhosis Chronic alcoholism Third Spacing (cont’d) ◦ Prevents liver from producing albumin, which lowers capillary oncotic pressure High vascular hydrostatic pressure ◦ Pushes abnormal volumes of fluid from the vessels Heart failure Renal failure Other vascular fluid overload 61 Treatment – Osmotic diuretics are used to mobilize some of the fluid back into the blood vessels for elimination by the kidneys Third Spacing (cont’d) 62 Types of fluid volume excess – Fluid Volume Excess ◦ Isotonic fluid excess Hypervolemia Edema ◦ Hypotonic fluid excess Risk factors that predispose Water intoxication individuals to fluid volume excess ­­ ◦ Individuals of certain age Elderly (due to ↓ heart and kidney function) Children < age 2 (due to immature kidneys) Children ages 2 – 12 years (due to unstable regulatory responses) 63 Risk factors (cont’d) – Fluid Volume Excess (cont’d) Stimulates the stress response, which releases cortisol, ADH, and aldosterone → promotes water and sodium retention Cardiovascular disease causes sodium and water retention Renal disease leads to abnormal retention of water, sodium, and potassium Long­term glucocorticoid therapy Drugs that act to retain sodium and fluids Reduces the pumping strength of the heart Reduces blood flow to the kidneys ◦ Acute illness ◦ Chronic illness ◦ Medications 64 Risk factors (cont’d) – Fluid Volume Excess (cont’d) Lab findings – Decreased hematocrit and BUN due to hemodilution Serum osmolarity is low ◦ Patients receiving IV fluids ◦ Returns to normal once excess fluid is removed Serum sodium is very low Low PO2 and PCO2 Chest x­ray may show pleural effusion Decreased pH due to respiratory 65 Clinical manifestations – Fluid Volume Excess (cont’d) Legs, ankles, feet, and hands in ambulatory individuals Sacrum and back in bedridden clients Indicates local obstruction of veins Edematous skin is often tight and shiny due to decreased circulation in swollen tissue ◦ Peripheral edema ◦ Edema in the legs and feet ◦ Puffiness in the face and around the eyes (periorbital edema) ◦ Tense or bulging fontanels in children less than 1 year of age 66 Associated with heart or kidney problems Clinical manifestations (cont’d) – Fluid Volume Excess (cont’d) ◦ Pitting edema ◦ High central venous pressure ◦ Venous congestion Hepatomegaly Splenomegaly Distended neck veins when HOB is elevated Delayed hand vein emptying when hand is raised above the heart for 3 – 5 seconds ◦ Decreased urine output if cardiac or renal function is impaired ◦ Weight gain of 3lbs over 2 – 5 days ◦ Full/bounding pulse, warm extremities 67 Treatment – Fluid Volume Excess (cont’d) ◦ Restrict fluid intake to 1,000 – 1,500mL/day ◦ Maintain sodium restriction ◦ Maintain IV access ◦ Administer diuretics ◦ Increase protein intake to increase capillary oncotic pressure to pull fluid out of the tissues ◦ Monitor respiratory status ◦ Monitor venous engorgement ◦ Monitor I&O, daily weight ◦ Assess for edema 68 Hypervolemia = gain of fluid and Isotonic Fluid Excess solute (sodium) in proportional amounts Edema = excess tissue (interstitial) ◦ Overall gain in the extracellular fluid without a change in serum osmolarity fluid throughout the body or specific to a body tissue or organ Causes ­­ ◦ Renal failure ◦ Rapid infusion of isotonic fluid Decreased excretion of water and sodium 6 Exceeds the ability to compensate by the heart 9 Causes (cont’d) – Isotonic Fluid Excess (cont’d) Venous congestion Decreased renal blood flow leading to decreased renal excretion of fluid and sodium ◦ Heart failure ◦ High corticosteroid levels, which results in sodium and water retention ◦ High aldosterone levels, which results in sodium and water retention Stress response Adrenal dysfunction Therapy Stress response 70 Gain of more fluid than solute Hypotonic Fluid Excess (sodium) ◦ Creates fluid volume excess ◦ Results in a deficit of sodium ◦ Serum osmolarity decreases Causes – Causes hypotonic extracellular fluid that gets pulled into the cells Cells swell, and cerebral edema occurs ◦ Frequent use of plain water enemas ◦ Multiple nasogastric tube or bladder irrigations with plain water ◦ Infusing hypotonic solutions too rapidly 71 Causes (cont’d) – Hypotonic Fluid Excess (cont’d) SIADH causes the kidneys to retain large amounts of water without retaining sodium ◦ Increased release of ADH ◦ Psychogenic polydipsia Stress Surgery, anesthesia Opioid analgesics, pain Tumors of the lung or brain Creates hypotonic extracellular fluid, which is drawn into the cells Highly concentrated urine with low urine volume Compulsive drinking of excessive amounts of water associated with psychiatric disorders (i.e. 72 some types of schizophrenia) Causes (cont’d) – Hypotonic Fluid Excess (cont’d) ◦ Severe or prolonged isotonic fluid volume excess Compensated by increased urine output Clients with heart failure, renal failure, and diabetes are sensitive to excess fluid administration Hydrostatic pressure = the pushing Capillary Fluid Movement force of a fluid against the walls of the space it occupies ◦ Generated by the heart’s pumping action ◦ Varies within the vascular system 73 Oncotic pressure = the pulling force Capillary Fluid Movement (cont’d) ◦ Albumin is a pulling force for water exerted by colloids in a solution Causes of low capillary oncotic pressure ­­ Maintains normal serum oncotic pressure Maintains adequate vascular fluid volume ◦ Injury or inflammation (trauma, burns, sepsis) Increases capillary permeability Allows fluids and proteins to leak from the vessels ◦ Malnutrition or liver dysfunction 74 Starling’s Law Capillary Fluid Movement (cont’d) ◦ Filtration = movement of fluid into or out of the capillary, determined by the pushing and pulling forces ◦ At the arterial end of the capillary, capillary hydrostatic pressure exceeds capillary oncotic pressure Fluid movement is from the capillary into the tissue Carries nutrients to the tissues ◦ At the venous end of the capillary, capillary hydrostatic pressure is less than capillary oncotic pressure Fluid movement is into the capillary from the 75 Edema = soft tissue swelling due to Edema expansion of the interstitial volume Increased capillary hydrostatic ◦ Can be localized or generalized ◦ Fluid moves from the capillaries into the interstitial space and back again, carrying wastes with it pressure ◦ Forces more fluid out of the arterial end of the capillary ◦ Draws less fluid back into the venous end of the capillary ◦ Results in edema as fluid accumulates in 76 Decreased capillary oncotic pressure Edema (cont’d) Causes ◦ Disrupts normal movement of fluid into and out of the capillaries ◦ Weaker pulling pressure allows more fluid to be pushed out of the arterial end of the capillary ◦ Unable to draw adequate amount of fluid back into the venous end of the capillary ◦ Results in edema ◦ Hypertension ◦ Hypervolemia, lymphedema ◦ Renal failure 77 Lymphedema occurs when a blockage Edema (cont’d) in the lymphatic system prevents lymph fluid from draining adequately; as the fluid accumulates, swelling continues ◦ Lymphatic obstruction ◦ Surgical removal of lymph nodes 78 Renal failure causes decreased renal Edema (cont’d) perfusion leading to excess aldosterone in the blood ◦ Causes water retention that elevates the blood pressure ◦ Increases hydrostatic pressure within the capillaries, which forces more fluid into the tissues ◦ Results in edema 79 Inability of the heart to pump enough Congestive Heart Failure (CHF) blood to meet the metabolic needsof the tissues of the body Associated with hypertension, myocardial infarction (MI), valvular disease Left ventricular failure seen with pulmonary edema Right ventricular failure seen with edema in the lower extremities Failure tends to occur in both ventricles, so client will present with 80 Fluid and electrolyte imbalances seen CHF (cont’d) with CHF – ◦ Fluid volume excess ◦ Hyponatremia ◦ Hypokalemia Decreased renal blood flow associated with decreased cardiac output ADH causes greater retention of water, diluting serum sodium level Caused by diuretics, vomiting, and diarrhea Pulmonary congestion interferes with carbon dioxide elimination from the lungs Anoxic tissue releases lactic acid 81 ◦ Respiratory acidosis ◦ Metabolic acidosis Fluid and electrolyte imbalances CHF (cont’d) (cont’d) ­­ ◦ Edema Signs and symptoms – Shift of intravascular fluid into interstitial tissue due to increase in hydrostatic pressure from excessive venous blood volume ◦ Fatigue due to decreased cardiac output ◦ Dyspnea 82 ◦ Decreased urine output due to secretion of Cardiac output is inadequate to provide for body’s oxygen requirements Paroxysmal nocturnal dyspnea occurs when client is in a recumbent position because edema fluid from the extremities returns to the bloodstream, increasing cardiac preload Signs and symptoms (cont’d) – CHF (cont’d) ◦ Cough ◦ Tachycardia ◦ Peripheral edema ◦ Pulmonary edema ◦ Distention of the peripheral veins from elevated venous pressure ◦ Orthopnea Visible in the hands, face, and neck Increased pulmonary venous pressure forces serum and blood cells in the alveoli Severe dyspnea, coughing, pink frothy sputum Increased interstitial edema increases the work of breathing Upright position fosters air exchange 83 Signs and symptoms (cont’d) – CHF (cont’d) ◦ Nocturia ◦ Cardiomegaly Oxygen demand reduced at night, decreasing renal constriction and increasing glomerular filtration rate Hypertrophy of the myocardium that helps to maintain stroke volume Nursing interventions – Give diuretics per IV ◦ Lessen cardiac preload and afterload ◦ Administer ACE inhibitors (arterial vasodilators) ◦ Restrict fluids ◦ Monitor I&O 84 Pulmonary edema is a medical Pulmonary Edema emergency ◦ Place patient in high Fowler’s position ◦ Administer oxygen ◦ Administer IV morphine Signs and symptoms – Reduces preload through peripheral dilation Reduces afterload through decreased blood pressure Reduces anxiety ◦ Tachypnea, dyspnea, labored breathing, cough, moist rales, decreased oxygen saturation ◦ Third spacing as fluids are forced out of 85 1. 2. Colloids 3. Hydrating solutions 4. Hypertonic­hyperosmolar preparations 5. Blood or blood components Crystalloids ­­ Capable of crystallization Forms a solution Can diffuse through membranes Includes electrolyte solutions that Basic Classifications of Infusates Crystalloids 86 Colloids – Cannot form a solution (does not dissolve) Cloudy in appearance Raises osmotic pressure Plasma or volume expander Types of colloids ­­ ◦ Albumin ◦ Dextran ◦ Plasmanate ◦ Hetastarch Classifications of Infusates (cont’d) 87 Hydrating Solutions (cont’d) – Supplements calorie intake Supplies nutrients Provides free water ◦ Maintenance ◦ Rehydration Classifications of Infusates (cont’d) Promotes effective renal output Frequently used hydrating solutions ◦ Dextrose 2½% in 0.45% saline ◦ Dextrose 5% in water (D5W) ◦ Dextrose 5% in 0.45% saline ◦ Dextrose 5% in 0.2% saline ◦ Sodium chloride 0.45% 88 Hydrating Solutions (cont’d) – Electrolytes in IV solutions are measured in mEq/L Milliequivalents measure how many chemically active ions are present in a solution Sodium chloride contains 154 mEq/L of sodium and 154 mEq/L of chloride, which equals 308 mOsm/L 0.45% NaCl (1/2 strength saline) has 77 mEq/L of sodium and 77 mEq/L of chloride, which equals 154 mOsm/L 89 Classifications of Infusates (cont’d) Dextrose Solutions – Manufactured as a percentage of the concentration in water or sodium chloride Expressed as the number of grams of solute per 100mL of solvent 5% dextrose in water solution contains 5g of dextrose in 100mL of water Classifications of Infusates (cont’d) 90 D5W Isotonic Infusions ◦ Osmolarity = 252.52 mOsm/L ◦ Best solution for hydration ◦ Does not contain electrolytes ◦ Not given to patient with increased intracranial pressure ◦ ADH secretion is increased as a stress response to surgery Isotonic in bag Hypotonic once dextrose metabolized ◦ Hypokalemia can occur due to cellular use of glucose Potassium shifts from the extracellular fluid to the intracellular fluid 91 Use cautiously in early post­operative period to prevent water intoxication D5W (cont’d) ­­ Isotonic Infusions (cont’d) ◦ Use cautiously in patients with signs of fluid overload and congestive heart failure ◦ May alter insulin/oral hypoglycemic needs in diabetics ◦ Should not be used in patients with allergies to corn and corn products ◦ Medication incompatibilities – Contraindicated in diabetic coma Dehydration with rapid infusion due to osmotic diuresis Ampicillin Diazepam Erythromycin Fat emulsions Phenytoin sodium Procainamide 92 0.9% normal saline (NS) Isotonic Infusions (cont’d) ◦ Osmolarity = 308 mOsm/L ◦ Only infusate compatible with a blood infusion ◦ Maintains patency of heparin locks ◦ Used as a diluent for medications ◦ Replaces extracellular fluid losses by expanding intravascular space ◦ Corrects hyponatremia ◦ Used to treat hypovolemia ◦ Can cause intravascular overload ◦ Can cause hypokalemia Monitor I&O 93 NS (cont’d) – Isotonic Infusions (cont’d) ◦ Can cause hypernatremia ◦ Does not provide free water or calories ◦ Used with caution in certain patients Decreased renal function Altered circulatory function Elderly Sodium may be retained in intraoperative and early post­operative situations Excessive sodium retention when used with glucocorticoids Contraindicated in patients with edema and sodium retention 94 NS (cont’d) – Isotonic Infusions (cont’d) ◦ Medication incompatibilities – Amphotericin B (antifungal) Chlordiazepoxide HCl (Librium) Diazepam Fat emulsions Levarterenol (norepinephrine) Mannitol Methylprednisolone sodium succinate (Solu­Medrol) 95 The body is in a state of homeostasis IV Fluid Reminders when the serum osmolarity is the same as other body fluids ◦ Approximately 280 – 300 mOsm/L To change the osmolarity, glucose and/or electrolytes must be added to the solvent ◦ Increases the total number of particles in the solution ◦ Increases osmotic pressure 96 ...
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This note was uploaded on 02/01/2011 for the course PNR 182 taught by Professor Toole during the Spring '10 term at Orangeburg-Calhoun Technical College.

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