Iv fluids

IV Fluids

1. IV Infusion: Types, Calculation and Nursing Consideration Presented by Bishuka Adhikari

2. Objectives At the end of seminar, participants will be able to: define intravenous (IV) infusion. enlist purposes of IV infusion. describe solutions used for IV infusion . describe the equipments used in IV infusion. calculate the flow rate for a infusion. describe the factors affecting flow rate. enlist nursing considerations in IV therapy. describe complications that may occur following infusion.

3. Definition The administration of medication or solution into the patient’s vein . (typically using only the pressure supplied by gravity )  C ommonly referred to as drips.

4. Purposes To supply fluid and electrolytes. To provide fluid and electrolyte replacement. To provide food in the form of glucose, amino acids and vitamins. To inject drugs into the body through the vein in emergency conditions for quick action.

5. Types of solutions for iv infusion A. Colloid solutions Contain large molecules that don’t pass the cell membranes. When infused, they remain in the intravascular compartment and expand the intravascular volume and they draw fluid from extravascular spaces via their higher osmotic pressure. always hypertonic. Eg- Albumin, Haemacele, Dextran

6. Types of solutions for iv infusion B. Crystalloid solutions C ontain small molecules that flow easily across the cell membranes allowing for transfer from the blood stream into the cells and body tissues. Increases fluid volume in both interstitial and intravascular spaces. May be isotonic, hypotonic or hypertonic. Eg- NS, RL, 5% Dextrose

7. Replacement of blood loss Crystalloid/colloid solutions improves perfusion but not O 2 carrying capacity of blood. 3 ml of crystalloid infusion replaces 1 ml of blood lost for volume replacement. Colloid infusion= Blood loss (1:1 ratio) only in terms of replacing volume.

8. Tonicity The measurement of osmotic pressure of the solution. On the basis of tonicity: Isotonic fluids Hypotonic solutions Hypertonic solutions

9. 1. Isotonic fluids It has same concentration of solutes as plasma, therefore remains in the vascular compartment, expanding vascular volume. Examples: 0.9% sodium chloride ( Normal saline) Ringer’s lactate solution (RL) 5% dextrose in water (D5W)

10. 0.9 % sodium chloride ( Normal saline) Composition: Na+ = 154mEq/L, Cl ¯=154mEq/L Osmolarity : 308 mOsm /L Indication: Intravascular volume expander. only solution that may be administered with blood products. Hypercalcemia .

11. 0.9 % sodium chloride ( Normal saline) 1 liter of normal saline 0.9% meets the usual daily requirement of these electrolytes in an adult. Nursing consideration Administer cautiously, because it may cause intravascular volume overload and pulmonary edema in clients with heart failure and renal failure.

12. Ringer’s lactate solution (RL) contains multiple electrolytes in roughly the same concentration as found in plasma (solution is lacking in Mg++). Also called Hartmann’s solution or physiological solution. provides 9 calories/L. Composition per liters: Na+ = 130 mEq /L K+ = 4 mEq /L Ca ++ = 3mEq/L Cl ¯=109 mEq /L Lactate = 28 mEq /L

13. Ringer’s lactate solution (RL) Osmolarity : 274 mOsm /L Indications: Burns Gastrointestinal fluid losses, especially below the pylorus (diarrhea, bile juice) Dehydration Blood loss Hypovolemia secondary to third space loss

14. Ringer’s lactate solution (RL) Nursing considerations similar to serum expect it does not contain magnesium. contraindicated in renal failure and liver disease. contains potassium and can cause hyperkalemia in renal failure. should not be given with pH> 7.5, as bicarbonate is formed causing alkalosis.

15. 5% dextrose in water (D5W) An isotonic solution that supplies 170 calories/L (1 gm dextrose gives 3.4 kilocalories) and free water to aid in renal excretion of solutes. Composition per liter: 50 gm of dextrose (no electrolytes) Osmolarity : 278 mOsm /L Indications Replacement of water losses in dehydration Hypernatremia Diluents for medication administration

16. 5% dextrose in water (D5W) Nursing consideration Converts to hypotonic solution as dextrose is metabolized by body. It can cause water intoxication. Contraindicated in head injury because it may cause increased intracranial pressure. Should not be used for fluid resuscitation as it can cause hyperglycemia.

17. 5% dextrose in water (D5W) Nursing consideration Should not be used in excessive volumes in the early postoperative period. Should be used with caution in patients with renal or cardiac disease because of risk of fluid overload.

18. 2. Hypotonic solutions Hypotonic fluids have tonicity less than that of body fluids and they are drawn from the intravascular space into intracellular and interstitial spaces. A solution with lower osmolality than blood serum. Examples: 0.45% sodium chloride ( Half strength saline). Composition per liter: Na+ = 77 mEq /L, Cl ¯=77 mEq /L Osmolarity : 154mOsm /L

19. 2. Hypotonic solutions Indications Hypertonic dehydration Replacement of gastric fluid loss due to NG suctioning or vomiting. Diabetic ketoacidosis after NS infusion if blood glucose is still >250mg/dl.

20. 2. Hypotonic solutions Nursing considerations: May cause increase in intracranial pressure if administered too quickly. Do not administer to client at risk for third space fluid shift.

21. 3. Hypertonic solutions Hypertonic solutions have a tonicity greater than that of body fluids and draw fluid into the intravascular space. It has higher concentration of solutes than plasma, therefore causing fluid shift from the cells into the vascular compartment, expanding vascular volume.

22. 3. Hypertonic solutions Examples: 3% NaCl (hypertonic saline) 10% dextrose DNS (D5 0.9% NaCl ) Haemacele Dextran 40 in NS or 5% D5W

23. 3% NaCl (hypertonic saline) Composition per liter: Na+ = 513mEq/L, Cl ¯=513mEq/L Osmolarity : 1026 mOsm /L Indications: Used only in critical situations to treat hyponatremia Assists in removing intracellular fluid excess.

24. 3 % NaCl (hypertonic saline) Nursing considerations: Must be administered slowly and cautiously, as it can cause intravascular volume overload and pulmonary edema. Does not supply calories.

25. 10% Dextrose Composition per liter: 100 gm dextrose Indications: Free water replacement To provide calories Stand by solution for clients receiving TPN

26. 10% Dextrose Nursing considerations: Monitor for hyperglycemia May dilute plasma electrolytes and lead to imbalances Monitor for water excess May stimulate overproduction of insulin

27. DNS (D5 0.9% NaCl ) Composition per liter: Na+ = 154mEq/L, Cl ¯=154mEq/L Dextrose: 50 gm /L Indications: Hypotonic dehydration SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion) Addisonian crisis Nursing considerations - Administer cautiously in clients with heart failure and renal failure.

28. Haemacele Composition per 100 ml: Gelatin = 3.5 gm Na+= 14.5mmol K+= 0.51mmol Ca ++= 0.62mmol Cl ¯=14.5mmol Water for injection= 100 ml Traces of PO 4 ¯ and SO 4 ¯.

29. Haemacele Indications Plasma expander Shock (Renal) Large loss of blood Volume losses during and after surgery

30. Haemacele Nursing considerations Infusion of haemacele leads to hemodilution and thus lowers viscosity of the blood. Excretion completes in 48 hours after the end of infusion. No retention occurs, since the haemacele molecule can be degraded by endogenous proteases. Infuse only clear solutions. Citrated blood (preserved) should not be mixed with haemacele . If side effects occur, the infusion must be discontinued at once. The rate of infusion is controlled by monitoring the blood pressure.

31. Equipments used in IV infusion

32. Equipments used in IV infusion

33. Equipments used in IV infusion 2. Drip chamber a device used to allow gas (such as  air ) to rise out from a fluid so that it is not passed downstream. commonly employed in delivery systems of   IV therapy  and act to prevent air embolism. can be classified into macro-drip(about 10 to 20  gtts /ml ) and micro-drip (about 60 gtts /ml) based on their drop factors.

34. Equipments used in IV infusion a. M acrodrip   allows large volumes of fluid to flow from a bag into a collecting chamber and then into a patient, who  requires rapid  fluid resuscitation . delivers  10, 15, or 20 drops per milliliter of  a solution. Drop factor of tubing is 20 gtts = 1 mL (usually)  not usually used to deliver a small  amount of  IV solution  because  the interval between drips is so long that a clot may form at the tip of the  IVcatheter .

35. Equipments used in IV infusion Microdrip   delivers  relatively small measured amounts of IV solutions at specific flow rates  used for children and infants, or to infuse sensitive medications where precision in the  flow rate  is essential . Microdrip tubing (sometimes called minidrip ) comes in only one size: 60 gtt / mL.

36. Equipments used in IV infusion Microdrip (60 gtts /ml) Macrodrip (20 gtts /ml)

37. Equipments used in IV infusion 3 . Infusion pump infuses fluids, medication or nutrients into a patient's circulatory system.  can administer fluids in ways that would be impractically expensive or unreliable if performed manually by nursing staff.

38. Equipments used in IV infusion 4 . Syringe pump A syringe driver or syringe pump is a small infusion pump (some include infuse and withdraw capability), used to gradually administer small amounts of fluid (with or without medication) to a patient.

39. Equipments used in IV infusion INFUSION PUMP draws fluid from a standard bag of intravenous fluid and controls the rate of flow provides accurate and continuous therapy. can use any size bag of intravenous fluid. Some pumps are able to control a single intravenous line, whereas, other infusion pumps have 3 pumps built into one device .. SYRINGE PUMP Instead of drawing fluid from an infusion bag, intravenous medications are drawn into a syringe and installed into the device . contain a maximum volume of 50 ml used to administer medications that have very small hourly volumes (for example, usually less than 5 ml/ hr ).

40. Equipments used in IV infusion 5. Pressure bags This is an inflatable cuff placed around the fluid bag to force the fluid into the patient. can be used if the patient requires a high flow rate and the IV access device is of a large enough diameter to accommodate it.

41. Calculation of IV Infusion rate Drops/Minute = Total infusion volume x drop factor Total time of infusion in minutes Drop factor varies with equipment and is usually printed on administration set packaging. In macro-sets it varies from 10-20 (16 drops/ml). Micro-drip sets are always 60 drops/ml .

42. Factors affecting flow Flow is directly proportional to the height of the liquid column . Raising the height of the infusion container may improve a sluggish flow. Flow is directly proportional to the diameter of the tubing . The clamp on IV tubing regulates the flow by changing the tubing diameter. In addition, the flow is faster through large gauge rather than small gauge cannulas.

43. Factors affecting flow Flow is inversely proportional to the length of tubing . Adding extension tubing to an IV line decreases the flow. Flow is inversely proportional to the viscosity of fluid . Viscous IV fluids, such as blood, require a large cannula than do saline solutions

44. Factors affecting flow Because so many factors influence an IV set to gravity flow, a solution does not necessarily continue to run at the speed originally set. The flow rate is calculated when the solution is originally started and then monitored at least hourly

45. Nursing considerations in IV therapy Explain to the patient about the purpose of starting the IV infusion therapy. Maintain hand hygiene. Collect the equipments required in the bedside. Perform IV cannulation following the standard protocol. Always use DEHP free tubings . Maintain aseptic technique throughout the circuit connection. Connect the prepared IV tubing and do not let air entrance by flushing the tube first.

46. Nursing considerations in IV therapy Assess for prescribed rate, calculate the flow rate, use appropriate IV infusion equipments as per requirement. Label the administration set with any added medication, date and time. Iv stand height to be maintained within 18-24 inches. Instruct client to notify of any of the following conditions: Flow rate changes or solution stops dripping. Solution container is nearly empty. There is blood in IV tubing or at insertion site. There is discomfort or swelling at insertion site.

47. Nursing considerations in IV therapy Site inspection Monitor the flow rate timely. Inspect the IV cannulation site for infection. Flush the cannula with 0.9% NS every 8 hours.

48. Nursing considerations in IV therapy Cannula access and replacement Use aseptic/non-touch technique. Firmly wipe port or hub using friction with 2% CHX/ 70% isopropylalcohol for 30 secs and allow drying prior to access.

49. Nursing considerations in IV therapy Site care and maintainance Set change : IV: every 72 hours. Prior if clots formed. Parenteral nutrition : every 24 hours. Blood and blood product : discarded after use. Piercing of the bottle to escape air from collapsed infusion bottle is a wrong practice.

50. Nursing considerations in IV therapy At least every 8 hours, document solution, amount, infusion device, rate, site, location and condition of site and dressing. Certain IV additives should be avoided in specific disease state.

51. Nursing considerations in IV therapy Clients with diabetes mellitus should not receive dextrose. Clients with heart failure or otherwise at risk for excess fluid volume should not receive sodium in IV fluids; if sodium containing solutions are necessary, they should be infused cautiously and with use of an IV pump. Clients with liver disease should not receive RL because of possible lack of ability to convert lactate to bicarbonate. Clients with renal failure should not receive potassium additives in IV solutions because they cannot excrete it.

52. Complications of IV therapy 1. Infections Characterized by fever, chills, erythema, elevated WBC and possibly septic shock Nursing actions: Use strict septic technique. Change IV tubing and dressing. Monitor site for 48 hours, the catheter tip may be sent to lab for cultures if sepsis is suspected.

53. Complications of IV therapy 2. Air embolism Characterized by respiratory distress, chest pain, dyspnea, hypotension, weak and rapid pulse. Nursing actions: Clamp the catheter. Position the client in left Trendelenburg’s position. Administer Oxygen and call physician.

54. Complications of IV therapy 3. Hypersensitivity reactions Characterized by flushing, itching and urticaria . Nursing actions: Check client for allergies prior to administering medications. Stop the infusion. Notify the physician. Monitor vital signs.

55. Complications of IV therapy 4. Circulatory overload Characterized by cough, dyspnea, crackles, distended neck veins, tachycardia, hypertension, S 3 heart sounds. Nursing actions: Monitor the client’s IV infusion rates at least hourly. Monitor the client’s vital signs, intake, output, breath and heart sounds.

56. Complications of IV therapy 4. Circulatory overload For fluid volume overload: Slow or stop the infusion rate per order. Place the client in high fowler’s position. Administer oxygen and diuretics per order. Notify the physician.

57. Complications of IV therapy 5. Infiltration Characterized by localized swelling, coolness, pallor and discomfort at the IV site. Nursing actions - Discontinue infusion and remove needle. Apply warm compress to encourage absorption. Restart IV at another site.

58. Complications of IV therapy 6. Phlebitis Characterized by warmth, swelling, red streak at vein site, pain along the course of vein. Nursing actions: Discontinue infusion and remove the venous access device. Apply warm compress. Restart IV at another site. Dilute irritating medications and apply over prescribed amount of time.

59. References Nursing procedure manual, Hospital Nursing service, College of Nursing, BPKIHS, Dharan , 1 st edition, June 2011, Page no. 49-52. Carroll, Conn’s current therapy, Physical and chemical injuries, W.B Saunders Company, 1 st edition, 1986, Page no 929. Sandra, Clinical Nursing skills, Intravenous therapy, 4 th edition, 1996, page no 815, 822, 823. Roshan , J. Rijuta , J and J Health Science, Body fluid, 4 th edition, 2016, page no 9-15 https :// en.wikipedia.org/wiki/Intravenous_therapy cited on 5 th dec 2018 https:// medical-dictionary.thefreedictionary.com/microdrip cited on 5th dec 2018 https:// www.lhsc.on.ca/critical-care-trauma-centre/critical-care-trauma-centre-283 cited on 5th dec 2018 https:// www.rcn.org.uk/clinical-topics/infection-prevention-and-control/standards-for-infusion-therapy cited on 5th dec 2018

60. Thank you Rub the hub before use.