1. 1 Second semester 15 - 16 Chapter 16 Fluid and Chemical Balance Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

2. 2 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Body fluid is a mixture of water, chemicals (called electrolytes and nonelectrolytes), and blood cells. Water, the vehicle for transporting the chemicals, is the very essence of life. Water is not stored in any great reserve, daily replacement is the key to maintaining survival. Fluid and Chemical Balance

3. 3 Second semester 15 - 16 Body Fluid Body fluid is a mixture of:  Water: human body has 45% to 75%  Electrolytes: have electrical charge  Nonelectrolytes: do not have electrical charge  Blood cells: RBCs, Leukocytes, WBCs, Platelets Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

4. 4 Average distribution of body fluid Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

5. 5 Second semester 15 - 16 Intracellular / Extracellular Fluid  Intracellular fluid: Fluid inside cells (greatest portion of water in the body)  Extracellular fluid: Fluid outside cells ** Extracellular fluid is one of the following: 1. Interstitial fluid (fluid in tissues) 2. Intravascular fluid (the watery plasma, or serum, portion of blood) Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

6. 6 Second semester 15 - 16 Assessing a Client’s Fluid Status  Intake and output (I&O) measurement: one tool to assess fluid status by keeping record over a 24hr period.  Intake: Sum of all fluid consumed/instilled  Output: Sum of liquid eliminated from the body Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

7. 7 Second semester 15 - 16 Assessing a Client’s Fluid Status: Intake  All liquids client drinks  IV solutions given  Liquid equivalent of melted ice chips, which is half of the frozen volume  Foods that liquidize when swallowed: gelatin, ice cream, thin cooked cereal  Fluid instillations: tube feeds or tube irrigations Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

8. 8 Second semester 15 - 16 Assessing a Client’s Fluid Status: Output  Urine  Emesis (vomitus)  Blood loss  Diarrhea  Wound or tube drainage  Aspirated irrigations Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

9. 9 Second semester 15 - 16 Assessing Fluid Status  Calibrated containers used to measure liquid volumes. Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

10. 10 Second semester 15 - 16 Intake and output record Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

11. 11 Second semester 15 - 16 Hypovolemia: low volume in extracellular fluid compartments If untreated, hypovolemia results in dehydration Dehydration: fluid deficit in both extracellular & intracellular compartments. In addition to weight loss, it is evidenced by decreased skin turgor (usually checked over the sternum) Physical S&S of dehydration: Acute weight. loss, Oliguria, concentrated urine, sunken eyes, poor skin turgor, low BP, weak rapid pulse, dizziness. Common Fluid Imbalances Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

12. 12 Second semester 15 - 16 Hypervolemia: Excess water in the intravascular fluid compartment Edema (excess fluid is distributed to the interstitial space). Dependent edema: fluid accumulates in dependent areas of the body (influenced by gravity) Common Fluid Imbalances ( cont‘d ) Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

13. 13 Second semester 15 - 16 Third-spacing: movement of intravascular fluid to nonvascular fluid compartments where it becomes trapped and useless Peritoneum common place for fluid build-up Common Fluid Imbalances ( cont‘d ) Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

14. 14 Second semester 15 - 16  Treating the disorder contributing to the increased fluid volume  Restricting or limiting oral fluids  Reducing salt consumption  Discontinuing IV fluid infusions or reducing the infusing volume  Administering drugs that promote urine elimination  Using a combination of the above interventions Reducing Fluid Volume Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

15. 15 Second semester 15 - 16 Intravenous Fluids administration  Intravenous (IV) fluids are solutions infused into a client’s vein to:  Maintain or restore fluid balance when oral replacement is inadequate or impossible  Maintain or replace electrolytes  Administer water-soluble vitamins  Provide a source of calories  Administer drugs  Replace blood and blood products Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

16. 16 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Isotonic: Contains the same concentration of dissolved substances as normally found in plasma (0.9% saline (NS), Ringer's lactate ) Hypotonic: Contains fewer dissolved substances than normally found in plasma (Ex: 0.45% sodium chloride) Hypertonic: More concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment Types of Intravenous Solutions

17. 17 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance IV Solutions A. Isotonic solutions B. Hypotonic solutions (cell swelling) C. Hypertonic solutions (cell shrinkage)

18. 18 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Venipuncture (accessing the venous system by piercing a vein with a needle) Venipuncture device is inserted in veins of: Hand or forearm in adults Scalp in child Venipuncture

19. 19 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance 1. Use veins on the non dominant side. this reduces the potential for dislodging the device as a result of movement and use. 2. Do not use foot and leg veins. using foot and leg veins restricts mobility and increases the potential for blood clots. 3. If possible, do not use a vein on the side of previous breast surgery or in which vascular surgery has been performed for kidney dialysis. using such veins further compromises circulation and increases the potential for infection and poor healing. Selecting a Venipuncture Site

20. 20 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance 4. Choose a vein in a location unaffected by joint it's movement. a venipuncture device in such a location could become displaced more easily. 5. Look for a large vein, if a large-gauge needle or catheter is necessary. matching the needle and vein size prevents compromising circulation. 6. Avoid using veins on the inner surface of the wrist. this prevents pain and discomfort. Selecting a Venipuncture Site (cont'd)

21. 21 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance 7. Look for a vein proximal to the current site or in the opposite hand or arm. This promotes healing and decreases the risk of fluid leaking from the vein into the tissue. 8. Feel and look for a fairly straight vein. It is easier to thread the device into a straight vein. 9. Do not use a vein that appears inflamed or if the skin over the area looks impaired in any way. Use of such a site creates additional trauma Selecting a Venipuncture Site (cont'd)

22. 22 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance IV Solutions Before preparing the solution, the nurse inspects the container and determines that: Solution is the one prescribed Solution is clear and transparent Expiration date has not elapsed No leaks are present A separate label is attached identifying the type & amount of other drugs added and is the one the MD ordered.

23. 23 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Types of Tubing 1. Microdrip (small drops) chamber: standard volume of 60 drops/mL 2. Macrodrip (large drops) chamber: usually 15, and 20 drops/mL. Drop factor (number of drops/mL) is important in calculating infusion rate when infusion is done by gravity 3. Filtered tubing: removes air bubbles, un-dissolved drugs, bacteria, large substances Ex: PRBCs, parental nutrition, pediatrics

24. 24 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Techniques for Infusing Intravenous Solutions 1. Gravity infusion 2. Electronic infusion devices Infusion pumps Volumetric controllers

25. 25 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Complications associated with the infusion of IV solutions are : Circulatory overload (intravascular volume that becomes excessive). Infiltration (escape of IV fluid into the tissue). Phlebitis (inflammation of a vein). Thrombus formation (stationary blood clot). Pulmonary embolus (blood clot that travels to the lung). Infection (growth of microorganisms at the site or within the blood stream), and Air embolism (bubble of air traveling within the vascular system). Complications With IV Administration

26. 26 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Regulating the Infusion Rate The nurse is responsible for calculating, regulating, and maintaining the rate of infusion according to the physician's order. If an infusion device is used, the electronic equipment is programmed in milliliters per hour. If the solution is infused without an electronic infusion device (i.e., by gravity), the rate is calculated in drops (gtt) per minute. Formulas for calculating infusion rates are provided in Box 16-5. Infusion Monitoring and Maintenance

27. 27 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance calculating flow rate

28. 28 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

29. 29 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

30. 30 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance

31. 31 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Because the venipuncture is a type of wound, it is important to inspect the site routinely. The nurse documents its appearance in the client's record. A common practice is to change the dressing over the venipuncture site every 24 to 72 hours Caring for the Site

32. 32 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first (Skill 16-4). IV tubing is changed every 72 hours, depending on agency policy, with some exceptions. Replacing Equipment

33. 33 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Blood is collected, stored, and checked for safety and compatibility before it is administered as a transfusion. Blood Collection and Storage Blood donors are screened to ensure they are healthy and will not be endangered by the temporary loss in blood volume. Refrigerated blood can be stored for 21 to 35 days, after which it is discarded. Blood Safety Once collected, the donated blood is tested for syphilis, hepatitis, and human immunodeficiency virus (HIV) antibodies to exclude administering blood that may transmit these blood-borne diseases. Blood Administration

34. 34 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Antigens determine the characteristic blood group—A, B, AB, and O—and Rh factor. Rh positive means the protein is present; Rh negative means the protein is absent. Before donated blood is administered, the blood of the potential recipient is typed and mixed, or cross-matched, with a sample of the stored blood to determine whether the two are compatible. To avoid an incompatibility reaction, it is best to administer the same blood group and Rh factor. Blood Compatibility

35. 35 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Before administering blood, the nurse obtains and documents the client's vital signs to provide a baseline for comparison should the client have a transfusion reaction. Blood Transfusion

36. 36 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Catheter or Needle Gauge it generally is infused through a 16- to 20-gauge— preferably an 18-gauge—catheter or needle. Blood Transfusion Tubing Blood is administered through tubing referred to as a Y-set (Fig. 16-20). The normal saline always is administered before the blood is hung and follows after the blood has been infused. It also is used during the infusion if the client has a transfusion reaction Blood Transfusion Equipment

37. 37 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Figure 16-20 Blood transfusion tubing.

38. 38 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Usually occur within first 5-15 minutes of the transfusion Staff remains with client for the 1 st 15 minutes Incompatibility Febrile Septic Allergic Moderate chilling Overload Hypocalcaemia Transfusion Reactions

39. 39 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Total parenteral nutrition (TPN; hypertonic solution of nutrients designed to meet almost all caloric and nutritional needs) is preferred for clients who are severely malnourished or may not be able to consume food or liquids for a long period. Because TPN solutions are extremely concentrated, they must be delivered to an area where they are diluted in a fairly large volume of blood. This excludes peripheral veins. TPN solutions are infused through a catheter inserted into the subclavian or jugular vein; the tip terminates in the superior vena cava. This type of a catheter is referred to as a central venous catheter Total Parenteral Nutrition

40. 40 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing - B Fluid and Chemical Balance Figure 16-21 Central venous catheter inserted into the subclavian vein and threaded into the superior vena cava.