FLUID AND
ELECTROLYTE BALANCE
The physiological
functions and alterations of body fluid and acid-base balance are presented in
this chapter. The term body fluid is used to denote both water and
electrolytes, whereas the term body water refers to water alone. Homeostasis,
or equilibrium of the internal environment, refers to the state of balance of
body fluid.
PHYSIOLOGY OF FLUID AND ACID-BASE BALANCE
The body normally maintains a balance
between the amount of fluid taken in and the amount excreted. Health promotion
requires a maintenance of body fluid and acid-base balance.
Fluid Compartments
The body’s
fluid is contained within three compartments: cells, blood vessels, and the
tissue space (space between the cells and blood vessels). To understand this
concept, visualize cars on a freeway. The cars represent cells; the lanes
represent the blood vessels, and the space between the cars in the lanes
represents the tissue space. The freeway itself is the body. Just as traffic is
ongoing and continuous, fluids move constantly from one compartment to another
to accommodate the cell’s metabolic needs (Figure 37-1). Specific terms are
used in describing compartmentalized body fluid. The prefixes (see the
accompanying display) used with the root words for the compartments that
contain the body fluid give meaning to the following terms:
• Intracellular fluid: within the cell
• Intra vascular fluid: within blood vessels
• Interstitial fluid: between cells; fluid
that surrounds cells
There are two types
of body fluid: intracellular (ICF) and extracellular (ECF). Because
intravascular and interstitial fluid are outside the cells, these fluids are
extracellular. Key terms used in explaining the movement of molecules in body
fluids are:
• Solute: Substance dissolved in a solution
• Solvent: Liquid that contains a substance in solution
• Permeability: Capability of a substance, molecule, or
ion to diffuse through a membrane (covering of tissue over a surface, organ, or
separating spaces)
• Semipermeable: Selectively permeable (All membranes in
the body allow some solutes to pass through the membrane without restriction
but will prevent the passage of other solutes.)
Cells have permeable membranes that allow fluid and solutes to pass into
and out of the cell. Permeability allows the cell to acquire the nutrients it
needs from extracellular fluid to carry on metabolism and to eliminate
metabolic waste products.
Blood vessels have permeable membranes that bathe and feed the cells. The
intravascular fluid of arterioles carries oxygen and nutrients to the cells.
The venules take in the waste products from the cells’ metabolic activity.
Cells and capillaries form a meshlike structure that creates a tissue space
between cells and the vascular system to allow cellular access to the vascular
system. Interstitial space promotes access of the cells to the arterioles and
venules.
Body Water Distribution
Water is the largest
single constituent of the body, representing 45% to 75% of the body’s total
weight. About twothirds of the body fluid is intracellular. The remaining
one-third is extracellular, with one-fourth of this fluid being intravascular
and three-fourths being interstitial fluid. Bones are made up of nearly
one-third water, while the muscles and brain cells contain 70% water. Body fat
is essentially free of water; therefore, the ratio of water to body weight is
greater in leaner people than in obese people. Water is present in all body
tissues and cells, and serves two main functions: to act as a solvent for the
essential nutrients, so that they can be used by the body; and to transport
nutrients and oxygen from the blood to the cells and to remove waste material
and other substance from the cells back to the blood so they can be excreted by
the body. Water is also needed by the body to:
• Give shape and form to the cells
• Regulate body temperature
• Act as a lubricant in joints
• Cushion body organs
• Maintain peak physical performance
Water loss has a
negative effect on the body’s ability to function, because every 2% to 5% of
water loss results in a 30% decrease in work performance (Kloss, 1995; Kleiner,
1999).
Electrolytes
An electrolyte is
a compound that, when dissolved in water or another solvent, forms or
dissociates into ions (electrically charged particles) (Figure 37-2). The
electrolytes provide inorganic chemicals for cellular reactions and control
mechanisms. Electrolytes have special physiological functions in the body that
promote neuromuscular irritability, maintain body fluid osmolarity, regulate
acid-base balance, and distribute body fluids between the fluid compartments.
Electrolytes are measured in terms of their electrical combining power, the
quantities of cations and anions in a solution, expressed as milliequivalents
per liter (mEq/L). Because electrolytes produce either positively charged ions
(cations) or negatively charged ions (anions), they are critical regulators in
the distribution of body fluid. The main electrolytes in body fluid are:
sodium (Na+),
potassium (K+), calcium (Ca2+), and magnesium (Mg2+). Table 37-1 discusses the
distribution of electrolytes in body fluid, their regulatory functions, and
dietary sources. As shown in Table 37-1,
the extracellular fluid contains the largest quantities of sodium, chloride,
and bicarbonate ions, but only small quantities of potassium, calcium,
magnesium, phosphate, sulfate, and organic acid ions. The intracellular fluid
contains only small quantities of sodium and chloride ions and almost no
calcium ions. Large quantities of potassium and phosphate ions with moderate
quantities of magnesium and sulfate ions are contained within intracellular
fluid (see the accompanying display).
Movement of Body Fluids
The physiological
forces that affect the movement of body fluids through cell walls and capillaries
can be perceived as a mass-transportation system that carries traffic between
the compartments. These forces transport molecules of water, foods, gases,
wastes, and ions to maintain a physiological balance between extracellular and
intracellular fluid volumes. These transport processes account for fluid shifts
between the compartments (Table 37-2).
Figure
37-3 The process of diffusion. A. A small lump of
sugar is placed in a beaker of water, its molecules dissolve and begin to diffuse outward. B., C. The sugar molecules
continue to diffuse through the water from an area of greater concentration to
an area of lesser concentration. D. Over a long period of time, the sugar
molecules are evenly distributed throughout the water, reaching a state of
equilibrium. Example of diffusion in the human body: Oxygen diffuses from an
alveolus in a lung, where it is in greater concentration, across the capillary
membrane, into a red blood cell, where it is in lesser concentration.
Regulators of Fluid Balance
The body has many
regulators that maintain fluid balance, including fluid and food intake, skin,
lungs, gastrointestinal tract, and kidneys. When all organs are functioning
normally, the body is able to maintain homeostasis.
Fluid and Food Intake and
Loss
There are three
natural sources by which water enters the body: oral liquids; water in foods;
and water formed by oxidation of foods. A normal diet provides the electrolytes
required by the body (see the accompanying display for the typical daily amount
of body fluid intake for an adult). Body fluid is replenished by the ingestion
of liquids and food products such as meats and vegetables, which contain 65% to
97% water. The third source of body fluid is the metabolism of foods, which
yields water of oxidation. The kidneys excrete the largest quantity of fluid;
other avenues for water loss are the lungs, skin, and gastrointestinal tract.
Skin
An estimated water
loss of 300 to 400 ml per day occurs by diffusion through the skin of an adult.
Because the person is not aware of this water loss, it is called insensible
loss. Water is also lost through the skin by perspiration; however, the
total amount of water lost by perspiration can vary from 1.5 to
Lungs
An estimated
insensible water loss of 300 to 400 ml per day occurs in an adult through
expired air, which is saturated with water vapor. This amount may vary with the
rate and depth of respirations.
Gastrointestinal Tract
Although a large amount of fluid—about 8,000 ml
per day in the adult—is secreted into the gastrointestinal tract, almost all of
this fluid is reabsorbed by the body. In adults, about 200 ml of water is lost
per day in feces. Severe diarrhea can cause a fluid and electrolyte deficit
because the gastrointestinal fluids contain a large amount of electrolytes.
Kidneys
The kidneys play a
major role in maintaining fluid balance by excreting 1,200 to 1,500 ml/day in
the adult. The excretion of water by healthy kidneys is proportional to the
fluid ingested and the amount of waste or solutes excreted. When an
extracellular fluid volume deficit occurs, hormones play a key role in
restoring the extracellular fluid volume. The release of the following hormones
into circulation causes the kidneys to conserve water:
• Antidiuretic hormone (ADH) from the posterior pituitary gland acts on the
distal tubules of the kidneys to reabsorb water.
• Aldosterone (produced in the adrenal cortex) causes the reabsorption of
sodium from the renal tubules. The increased reabsorption of sodium causes
water retention in the extracellular fluid, increasing its volume.
• Renin, which is released from the juxtaglomerular cells of the kidneys,
promotes vasoconstriction and the release of aldosterone. The interaction of
these hormones with regard to renal functions serves as the body’s compensatory
mechanism
to maintain
homeostasis. Sodium is the main electrolyte that promotes the retention of
water. An intravascular water deficit causes the renal tubules to reabsorb more
sodium into circulation. Because water molecules go with the sodium ions, the
intravascular water deficit is corrected by this action of the renal tubules.
FACTORS AFFECTING FLUID AND ELECTROLYTE BALANCE
The balance of fluids
and electrolytes in the body is dependent on many factors and will vary
depending on such elements as age and lifestyle.
Age Body water
distribution is relative to body size. The smaller the body, the larger the
fluid content:
• Adult, 60% water
• Child, 60% to 77% water
• Infant, 77% water
• Embryo, 97% water
In the elderly, body
water diminishes because of tissue loss; the percentage of total body weight
that is fluid may be reduced to 45% to 50% in persons over age 65. Caution must
be used when administering diuretics, especially thiazide diuretics, to the
elderly to prevent diuretic-induced electrolyte disturbances.
Lifestyle
Loss of body fluids
can result from stress, exercise, or a warm or humid environment. Stress leads
to increased blood volume and decreased urine production, with a subsequent
intensification of antidiuretic hormone levels. Sweating and exercise cause the
body to lose water and sodium, thus necessitating electrolyte replacement and
intensifying the thirst response. Warm climates can exert a similar effect. An
individual’s diet will also determine fluid and electrolyte levels. Adequate
intake of fluids, carbohydrates, potassium, calcium, sodium, fats, and protein
is essential in helping the body maintain homeostatis and function properly.
Dehydration is one of the most common yet most serious fluid imbalances that
can occur from poor monitoring of diet. One nursing goal is to ensure that all
clients understand the role water plays in health and to see that clients
understand how to maintain adequate hydration status.
DISTURBANCES IN ELECTROLYTE BALANCE
The clinical
management of clients experiencing disturbances in sodium, potassium, calcium,
magnesium, and phosphate is presented using the functional health pattern
model. See Table 37-3 for the causes, clinical manifestations, and nursing
interventions for these electrolyte disturbances. Because chloride has several
characteristics similar to other ions, a brief discussion of chloride imbalance
is also presented. Acid-base imbalances caused by a disturbance in the level of
either carbonic acid or bicarbonate are also presented using the functional
health pattern model.
Electrolyte Disturbances
In health, normal
homeostatic mechanisms function to maintain electrolyte and acid-base balance.
In illness, one or more of the regulating mechanisms may be affected, or the
imbalance may become too great for the body to correct without treatment. Refer
to Chapter 28, Table 28-7, for the normal laboratory values of electrolytes.
Sodium
Sodium is the primary
determinant of extracellular fluid concentration because of its high
concentration and inability to cross the cell membrane easily. As discussed in
Table 37-3, alterations in sodium concentration can produce profound central
nervous system effects on cognition and sensory perception and on the
circulating blood volume. When the kidneys reabsorb sodium ions, chloride and
water are reabsorbed with the sodium to maintain the body’s fluid volume.
Hyponatremia
Hyponatremia is a
deficit in the extracellular level of sodium. With hyponatremia, there is
either a sodium deficit or a water excess; a hypo-osmolar state exists because
the ratio of water to sodium is too high. The water moves out of the vascular
space into the interstitial space and then into the intracellular space,
causing edema. The low extracellular serum sodium causes water to enter the
cells in the brain, thereby producing cerebral edema as manifested by the
cognitive and sensory changes listed in Table 37-3.
Hypernatremia
Hypernatremia
is an excess in the extracellular level of sodium. With
an excess of sodium or a loss of water, a hyperosmolar state exists because the
ratio of sodium to water is too high. This ratio causes an increase in the
extracellular osmotic pressure, which pulls fluid out of the cells into the
extracellular space. The symptoms of this increase depend on the cause and the
location of the edema (see Table 37-3).
Potassium
The normal range of
extracellular potassium is narrow (3.5–5.0 mEq/L). The slightest decrease or
increase can cause serious or life-threatening effects on physiological
functions. A reciprocal relationship exists between sodium and potassium; large
sodium intake results in an increased loss of potassium, and vice versa. When
potassium is lost from the cells, sodium enters the cells. Intracellular
potassium deficit may coexist with an excess of extracellular potassium. There
are two main categories of diuretics that can cause hypokalemia:
1. Potassium-wasting diuretics excrete potassium and other
electrolytes, such as sodium and chloride.
2. Potassium-sparing diuretics retain potassium but excrete
sodium and chloride.
Hypokalemia
Hypokalemia
is a decrease in the extracellular level of potassium.
Gastrointestinal-tract disturbances and the use of diuretics can place the
client at risk for hypokalemia and an acid-base imbalance (metabolic
alkalosis). Potassium-wasting diuretics can cause
NURSING ALERT
Hypokalemia
Hypokalemia can cause
a cardiac arrest when:
1. The potassium
level is less than 2.5 mEq/L.
2. The client is
taking digitalis (a drug that strengthens the contraction of the myocardium and
slows down the rate of the heart). Hypokalemia enhances the action of the
drug, causing toxicity.
Hyperkalemia
Hyperkalemia
is an increase in the extracellular level of potassium.
There are major drug groups that may cause hyperkalemia:
• Potassium-sparing diuretics
• Central nervous system agents
• Oral and intravenous replacement potassium salts Hyperkalemia can also
inhibit the action of digitalis.
Calcium
Most of the body’s
calcium (99%) is deposited in bone as phosphate and carbonate. The remaining 1%
is in the blood plasma (serum). Normally, 50% of the serum calcium is ionized
(physiologically active), with the remaining 50% bound to protein. Free,
ionized calcium is needed for cell membrane permeability. The calcium that is
bound to plasma protein cannot pass through the capillary wall and therefore
cannot leave the intravascular compartment. A stable blood level of calcium is maintained by a negative-feedback system
controlled by vitamin D, parathyroid hormone, calcitonin (thyrocalcitonin), and
the serum concentrations of calcium and phosphate ions. A decreased blood level
stimulates the parathyroid gland to secrete parathyroid hormone, which in turn
mobilizes the release of calcium from the bone, increases the renal
reabsorption, and increases intestinal absorption in the presence of vitamin D.
Likewise, calcitonin, secreted by the thyroid gland, reduces the blood calcium
concentration. Calcium ions are never completely absorbed from the
gastrointestinal tract. Dietary calcium absorption and utilization require an
adequate amount of protein and vitamin D. Besides being needed by the body for
bone and tooth formation, calcium is an important ion in the blood-clotting
mechanism and for maintaining the integrity of the neuromuscular system.
Hypocalcemia
Hypocalcemia
is a decrease in the extracellular level of calcium. The
rapid administration of citrated blood, alkalosis, and elevated levels of serum
albumin increase the activity of calcium binders, thereby decreasing the amount
of free calcium.
Hypercalcemia
Hypercalcemia
is an increase in the extracellular level of calcium. The
clinical symptoms result from a decrease in neuromuscular activity,
reabsorption of calcium from bone, and the kidney’s response to a high serum
calcium concentration.
Magnesium
Magnesium plays an
important role as a coenzyme in the metabolism of carbohydrates and proteins
and as a mediator in neuromuscular activity. Magnesium has the unique
characteristic of being the only cation that has a higher concentration in
cerebrospinal fluid than in extracellular fluid.
Hypomagnesemia
Hypomagnesemia
is a decrease in the extracellular level of magnesium and
usually occurs with hypokalemia and hypocalcemia. It is probably the most
undiagnosed electrolyte deficit because it is asymptomatic until the serum
level approaches 1.0 mEq/L; the normal range is 4.5–5.5 mEq/L (Kee &
Paulanka, 2000). Drugs that may cause hypomagnesemia include: digitalis,
potassium-wasting diuretics, cortisone, aminoglycosides, and amphotericin B;
the chronic use of laxatives may also cause the condition. Clinical
manifestations are related to the neuromuscular, neurologic, or cardiovascular
system (see Table 37-3).
NURSING ALERT
Potassium
Chloride
Never administer more
than 10 mEq of intravenous potassium chloride (KCl) per hour; the normal dose
of intravenous KCl is 20–40 mEq/L to infuse over an 8-hour period.
NURS I N G T I P
Serum
Calcium
Approximately 50% of
the serum calcium level is bound to protein. Correlate the serum calcium level
with the serum albumin level when evaluating the laboratory results. Any
change in serum protein will result in a change in the total serum calcium.
NURSING ALERT
Hypercalcemic
Crisis
A rapid increase in
the extracellular level of calcium (above 8 to 9 mEq/L) can trigger a
hypercalcemic crisis. To prevent a hypercalcemic crisis, provide adequate
hydration and administer diuretics or phosphate or both as prescribed by the
health care practitioner.
Hypermagnesemia
Hypermagnesemia
refers to an increase in the extracellular level of
magnesium. It rarely occurs from excessive dietary ingestion; however, overuse
of magnesiumcontaining drugs (antacids, laxatives, and intravenous magnesium
sulfate) can cause hypermagnesemia. The clinical manifestations of
hypermagnesemia are nonspecific (refer to Table 37-3).
Phosphate
Phosphate is the main
intracellular anion; it appears as phosphorus in the serum. Phosphorus is
similar to calcium in that vitamin D is needed for its reabsorption from the
renal tubules.
Hypophosphatemia
Hypophosphatemia
is a decreased extracellular level of phosphorus. An
increase in parathyroid hormone causes decreased renal reabsorption and
increased excretion of phosphates. The aim of nursing care is to protect the
client from injury and to correct the deficit (see Table 37-3).
Hyperphosphatemia
Hyperphosphatemia
is an increased extracellular level of phosphorus.
Excessive administration (oral or intravenous) of phosphate-containing
substances can cause hyperphosphatemia. Other causes of hyperphosphatemia are
hypoparathyroidism, renal insufficiency, and laxatives containing phosphate.
Chloride
As previously stated,
chloride and water move in the same direction as sodium ions, influencing the
osmolality of extracellular fluid. Although chloride losses usually follow
sodium losses, the proportion will differ because a loss of chloride can be
compensated for by an increase in bicarbonate. Therefore, signs and symptoms of
a chloride imbalance will be similar to those of a metabolic acid-base
imbalance, discussed later in this chapter. A deficit of either chloride or
potassium will lead to a deficiency of the other electrolyte.
Hypochloremia
Hypochloremia
is a decrease in the extracellular level of chloride.
Gastrointestinal tract losses may cause a decrease in chloride because of the
acid content of gastric juices, mainly hydrogen chloride. Because the
bicarbonate ion compensates for the loss of chloride, the client is at risk for
developing metabolic alkalosis. The signs and symptoms of hypochloremia are
muscle twitching and slow, shallow breathing. With a severe loss of chloride
and extracellular fluid volume, there may be a drop in blood pressure.
Hyperchloremia
Hyperchloremia is an
increase in the extracellular level of chloride. It usually occurs with
dehydration, hypernatremia, and metabolic acidosis. The signs and symptoms of
hyperchloremia are muscle weakness, deep, rapid breathing, and lethargy progressing
to unconsciousness if untreated.
ASSESSMENT
Assessment data are used
to identify clients who have potential or actual alterations in fluid volume.
Clients receiving certain treatments, such as medications and IV therapy, are
at risk for developing imbalances. The key nursing assessment indicators that
identify imbalances are daily weights, vital signs, intake and output, and the
physical findings of the skin, oral cavity, eyes, venous filling, and
neuromuscular system.
Health History
The nursing history
should elicit data specific to fluids (see the accompanying display for sample
topics to direct the interview).
Physical Examination
The nurse performs a
complete physical examination and identifies all abnormalities because fluid
alterations may affect any body system. The physical assessment of clients with
altered fluid status is discussed in this section: refer to Chapter 27 for
procedures on weight and vital sign measurement.
Daily Weight
Changes in the body’s
total fluid volume are indicated by weight; for instance, each kilogram (
Vital
Signs
Measurement of vital
signs provides the nurse with information regarding the client’s fluid,
electrolyte, and acid-base status and the body’s compensatory response for
maintaining balance. An elevated temperature places the client at risk for
dehydration caused by an increased loss of body fluid.
HEALTH
HISTORY
• Lifestyle (sociocultural and economic factors, stress, exercise)
• Dietary intake (recent changes in the amount and types of fluid and food,
increased thirst)
• Religion (whether illness has had an effect on beliefs or religion; query
whether the client would like a visit from his or her religious counselor)
• Weight (sudden gain or loss)
• Fluid output (recent changes in the frequency or amount of urine output)
• Gastrointestinal disturbances (prolonged vomiting, diarrhea, anorexia,
ulcers, hemorrhage)
• Fever and diaphoresis
• Draining wounds, burns, trauma
• Disease conditions that could upset homeostasis (renal disease, endocrine
disorders, neural malfunction, pulmonary disease)
• Therapeutic programs that can produce imbalances (special diets,
medications, chemotherapy, administration of intravenous fluid or total
parenteral nutrition, gastric or intestinal suction)
Changes in the pulse
rate, strength, and rhythm are indicative of fluid alterations. Fluid volume
alterations may cause the following pulse changes:
• Fluid volume deficit (FVD): increased pulse rate and weak pulse volume
• Fluid volume excess (FVE): increased pulse volume and third heart sound
Respiratory changes
are assessed by inspecting the movement of the chest wall, counting the rate,
and auscultating the lungs. Changes in the rate and depth may cause respiratory
acid-base imbalances or may be indicative of a compensatory response in
metabolic acidosis or alkalosis, as previously discussed in Table 37-4. Blood
pressure measurements can be used to assess the degree of FVD. FVD can lower
the blood pressure with or without orthostatic hypotension. A narrow pulse
pressure (less than
Intake and Output
Measure and record
the client’s intake and output for a 24-hour period to assess for an actual or
potential imbalance. A minimum intake of 1,500 ml is essential to balance
urinary output and the body’s insensible water loss. Intake includes all
liquids (e.g., ice cream, soup, gelatin, juice, and water) taken by mouth and
liquids administered through tube feedings (nasogastric or jejunostomy) and
parenterally (IV fluids and blood or its components). Output includes urine,
diarrhea, vomitus, and drainage from tubes such as through gastric suction. The
recording of intake and output data is usually referred to as the I&O.
Thirst
The most common
indicator of FVD is thirst. With a decrease in extracellular fluid volume or an
increase in the plasma osmolality, the hypothalamus triggers a thirst response.
Food
Intake
The intake of food
also contributes to maintaining extracellular fluid volume. One-third of the
body’s fluid needs are met by ingested food. Food also provides the body with
necessary electrolytes. See Chapter 38 for a complete discussion of metabolism.
Edema
Edema
(the detectable accumulation of increased interstitial
fluid) is the main symptom of FVE. Edema may be localized (confined to a
specific area) or generalized (occurring throughout the body’s tissue).
Localized edema is characterized by taut, smooth, shiny, pale skin. The body
may retain 5 to
• +0'' no pitting
• +1, 0''–1/4'' pitting (mild)
• +2, 1/4''–1/2'' pitting (moderate)
• +3, 1/2''–1'' pitting (severe)
• +4, greater than 1'' pitting (severe)
Skin Turgor
Skin
turgor is the normal resiliency of the skin. When
the skin is pinched and released, it springs back to a normal position because
of the outward pressure exerted by the cells and interstitial fluid. To measure
the client’s skin turgor, grasp and raise the skin with two fingers as follows:
• Adults: over the sternum, forehead, or inner aspect of the thigh
• Children: over the abdominal area or medial aspect of the thigh
NURSING T
I P
Monitoring Water Balance
The most accurate way to monitor water
balance is through daily body weight measurement because water constitutes 45%
to 75% of the body’s total weight.
NURSING ALERT
Dehydration in the Elderly
The elderly are prone to a fluid volume
deficit (dehydration), because the thirst mechanism in the medulla becomes less
responsive with aging.
NURS
I N G T I P
Skin Turgor in the Elderly
With aging, there are fewer elastic
fibers in the skin, resulting in reduced skin turgor. Assess the tongue for
creases or furrows to monitor
dehydration in the elderly (Hogstel,
2001). With dehydration there is a
decreased skin turgor, as manifested by lax skin that returns slowly to the
normal position. Increased skin turgor, which occurs with edema, is manifested
by smooth, taut, shiny skin that cannot be grasped and raised.
Buccal
(Oral) Cavity
Inspect the buccal
cavity. With FVD, there is a decrease in saliva, which causes sticky, dry
mucous membranes and dry cracked lips. The tongue has longitudinal furrows.
Eyes
Inspect the eyes. FVD
causes sunken eyes, dry conjunctiva, and decreased or absent tearing. Puffy
eyelids (periorbital edema, or papilledema) are characteristic of FVE; the
client may also have a history of blurred vision.
Jugular
and Hand Veins
Circulatory volume is
assessed by measuring venous filling of the jugular and hand veins. Place the
client in a low Fowler’s position. Then:
1. Palpate the jugular (neck) veins: FVE causes a distention in the jugular
veins (Figure 37-7).
2. Place the client’s hand below the heart level, and palpate the jugular
veins; with FVD there is decreased venous filling (flat neck veins).
Neuromuscular
System
Fluid and electrolyte
imbalances may cause neuromuscular alterations: The muscles lose their tone and
become soft and underdeveloped, and reflexes are diminished. Calcium and
magnesium imbalances cause an increase in neuromuscular irritability. To assess
for neuromuscular irritability perform the following tests:
1. Chvostek’s sign: Tap the facial nerve
2. Trousseau’s sign: Place a blood pressure cuff on the arm, inflate the cuff
slightly above the systolic pressure, leave the cuff inflated 2–3 minutes, and
deflate; carpal spasm or tetany indicates a positive response. A positive
Chvostek’s sign and Trousseau’s sign may occur with hypocalcemia and hypomagnesemia.
Other neurologic signs include inability to concentrate, confusion, and
emotional lability, as previously discussed in Tables 37-3 and 37-4.
Diagnostic and Laboratory Data
Biochemical
assessment is another essential source of objective data. Laboratory results
can be used to detect imbalances before clinical symptoms are assessed in the
physical examination. Laboratory tests used in assessing clients with common
alterations in extracellular fluid volume are discussed next; refer to Chapter
28 for the normal values presented in this section.
Hemoglobin and Hematocrit Indices
The hematocrit is
affected by changes in plasma volume. For instance, with severe dehydration and
hypovolemic shock, the hematocrit is increased, whereas overhydration decreases
the hematocrit. Hemoglobin levels are decreased with severe hemorrhage.
Osmolality
Osmolality
is a measurement of the total concentration of dissolved
particles (solutes) per kilogram of water. Osmolality measurements are
performed on both serum and urine samples to determine alterations in fluid and
Figure
37-7 Positioning the Client to Assess Jugular Vein
Distention electrolyte balance.
Osmolality can also be explained in relation
to the specific gravity of body fluids. Specific gravity expresses the weight
of the solution when compared with an equal volume of distilled water; the
osmolality of a solution can be estimated by the specific gravity.
Serum
Osmolality
Serum osmolality is a
measurement of the total concentration of dissolved particles per kilogram of
water in serum, recorded in milliosmoles per kilogram (mOsm/kg). The particles
measured in serum osmolality include electrolyte ions, such as sodium and
potassium, and electrically inactive substances dissolved in serum, such as glucose
and urea. Water and sodium are the main entities that control the osmolality of
body fluids. Serum sodium is responsible for 85% to 90% of the serum
osmolality. The normal serum osmolality is 275 to 295 mOsm/kg (Fischbach,
2000). It can increase with dehydration and loss of body water and decrease
with water excess. In clinical practice, the terms osmolality and osmolarity
(the concentration of solutes per liter of cellular fluid) are often used
interchangeably to refer to the concentration of body fluid. However, these
terms are actually different, in that osmolality refers to the concentration of
solutes in the total body water (solutes per kilogram of body weight) rather
than in cellular fluid. Figure 37-9 relates osmosis to the osmolality of a solution.
The appropriate term to use in intravenous fluid therapy is osmolarity (Bulechek
& McCloskey, 1999). An osmolaritic solution is described as:
• Hypotonic (hypo-osmolar) when there are less
solutes in proportion to the volume of water than is the case in the body
• Isotonic (iso-osmolar) when body water and solutes
(sodium) are in amounts equal to those in the body
• Hypertonic (hyperosmolar) when there are more
solutes in proportion to the volume of water than is the case in the body
Urine
Osmolality
Urine osmolality is a
measurement of the total concentration of dissolved particles per kilogram of
water in urine, recorded in milliosmoles per kilogram (mOsm/kg). The particles
measured in urine osmolality come from nitrogenous waste (creatinine, urea, and
uric acid), with urea contributing most. Urine osmolality varies greatly with
diet and fluid intake and reflects the ability of the kidney to adjust the
concentration of urine in order to maintain fluid balance. With normal kidney
function, a dehydrated client will have an elevated urine osmolality, whereas
clients with shock, hyperglycemia, hemoconcentration, and acidosis will have
elevations in both urine and serum osmolality.
Urine pH
The measurement of
the pH of urine reveals the hydrogen ion concentration of the urine to
determine its acid or alkaline status. When the kidney buffering system is compensating for either metabolic acidosis or
alkalosis, the pH of the urine should be within normal range (4.6–8.0). This is
considered a sign of normal function. However, when the renal compensatory
function fails to respond to the pH of the blood, the urine pH will increase
with acidosis and decrease in alkalosis.
Serum Albumin
Albumin is
synthesized in the liver from amino acids. Serum albumin plays an important
role in fluid and
NURS I N G T I P
Urine
Osmolality
Urine osmolality is a
more accurate indicator of hydration than is the specific gravity of urine.
Some medications and the presence of protein and glucose solutes in the urine
can give a false high specific gravity reading.
Figure 37-9 Osmosis as it relates to the osmolarity of a solution. The movement of
water through a membrane from a lower
concentration to a higher concentration is called osmosis. In a
hypotonic solution, the water moves into the cells, causing them to swell and
burst. The cells in the isotonic solution are normal in size and shape because
the same amount of water is entering and leaving the cells. Cells in the
hypertonic solution are losing water because water moves from a weaker
concentration inside the cell to a greater concentration outside the cell
membrane.
electrolyte balance
by maintaining the colloid osmotic pressure of blood, which prevents the
accumulation of fluid (edema) in the tissues. However, serum albumin has a
half-life of 21 days and fluctuates according to the level of hydration;
therefore, it is not a good indicator of acute alterations in protein
depletion. Clinically, this blood test is used to measure prolonged protein
depletion, which occurs in chronic malnutrition. Refer to Chapter 38 for a
discussion of serum albumin and pre-albumin.
NURSING DIAGNOSIS
In order to make a
nursing diagnosis, the nurse must be able to interpret assessment and
biochemical data and draw conclusions relative to the client’s imbalance. The
primary nursing diagnoses for clients with fluid imbalances are presented in
the accompanying display.
Excess Fluid Volume
Excess fluid volume
(EFV) exists when the client has increased interstitial and intravascular fluid
retention and edema. EFV is related to the excess fluid either in tissues of
the extremities (peripheral edema) or in lung tissues (pulmonary edema).
Factors that put the client at risk for EFV are:
• Excessive intake of fluids (e.g., intravenous therapy, sodium)
• Increased loss or decreased intake of protein (chronic diarrhea, burns,
kidney disease, malnutrition)
• Compromised regulatory mechanisms (kidney failure) • Decreased intravascular movement (impaired myocardial contractility)
• Lymphatic obstruction (cancer, surgical removal of lymph nodes, obesity)
• Medications (steroid excess)
• Allergic reaction
Assessment findings
in the client with FVE include acute weight gain; decreased serum osmolality
(less than 275 mOsm/kg), protein and albumin, BUN, Hgb, Hct; increased central
venous pressure (greater than 12–15 cm H2O); and signs and symptoms of edema.
The clinical manifestations of edema are relative to the area of involvement,
either pulmonary or peripheral (see the accompanying display).
Deficient Fluid Volume
Deficient fluid
volume (DFV) exists when the client experiences vascular, interstitial, or
intracellular dehydration. The degree of dehydration is classified as mild,
marked, severe, or fatal on the basis of the percentage of body weight lost. There
are three types of dehydration based on the proportion of fluid and particles
in the intracellular and extracellular spaces (see the accompanying display).
Kleiner (1999) reports that a portion of the general population may be
chronically mildly dehydrated based on the Nationwide Food Consumption Surveys.
According to Sansevero (1997), approximately 1 million
elderly people a year
are admitted to hospitals with iso- tonic dehydration, and 19% of emergency
room admissions were prompted by dehydration, frequent falling, or failure to
care for self. Mild dehydration, as little as 2% loss of body weight, results
in impaired physiological and performance responses, and may be misinterpreted
as a sign of aging and not hydration status (Kleiner, 1999). Assessment
findings in the client with DFV include thirst and weight loss, with the amount
varying with the degree of dehydration. With marked dehydration, the mucous
membranes and skin are dry. There is poor skin turgor; low-grade temperature
elevation; tachycardia; respirations 28 or greater; a decrease (10–15 mm Hg) in
systolic blood pressure; slowing in venous filling; a decrease in urine (less
than 25 ml per hour); concentrated urine; elevated Hct, Hgb, BUN, and an acid
blood pH (less than 7.4). Severe dehydration is characterized by the symptoms
of marked dehydration. Also, the skin becomes flushed. The systolic blood
pressure continues to drop (
NURSING DIAGNOSES
FOR FLUID ALTERATIONS
Excess
Fluid Volume related to:
• Excessive fluid intake secondary to excess sodium intake
• Compromised regulatory mechanism (renal and cardiac dysfunction)
• Inaccurate intravenous infusion rate
Deficient
Fluid Volume related to:
• Excessive fluid loss secondary to vomiting, blood loss, surgical drains and
tubes, diarrhea, and diuretics
Risk
for Deficient Fluid Volume related to:
• Extremes of age (very young or old) and weight
• NPO and fluid restrictions
• Increased fluid output from normal routes: vomiting, diarrhea, urine
• Increased fluid losses from drainage or suction routes: wounds, drains,
indwelling tubes (e.g., urine catheter, nasogastric suction)
• Loss of plasma associated with severe trauma and burns
• Disorders that impair fluid intake or absorption (immobility,
unconsciousness)
• Chronic disorders: congestive heart failure, pulmonary edema, chronic
obstructive lung disease, renal failure, diabetes, cancer, transplant
candidates
• Deficient knowledge related to factors influencing fluid requirements
(hypermetabolic states, hyperthermia, and dry, hot environment)
• Medications (e.g., diuretics)
Risk for Deficient Fluid Volume
Risk for fluid volume
deficit exists when the client is at high risk of developing vascular,
interstitial, or intracellular dehydration resulting from active or regulatory
losses of body water in excess of needs. The multiple factors that can place
the client at risk for FVD are listed in the preceding accompanying display.
Other Nursing Diagnoses
The relationship
between the primary nursing diagnoses just discussed and the secondary
diagnoses in clients with fluid imbalances are reciprocal: The primary
diagnoses influence and are influenced by the secondary diagnoses. Holistic
nursing requires that all diagnoses relative to clients be considered when
developing their plan of care.
Impaired Gas Exchange
Impaired gas exchange
related to a ventilation perfusion imbalance occurs when clients experience a
decreased passage of oxygen or carbon dioxide between the alveoli of the lungs
and the vascular system. This alteration is assessed by measuring the oxygen
and carbon dioxide content through arterial blood gas analysis or pulse
oximetry or both. Refer to Chapter 32 for further discussion of oxygenation.
Decreased Cardiac Output
Decreased cardiac
output occurs when the blood pumped by a client’s heart is reduced so much that
it is inadequate to meet the needs of the body’s tissue. This alteration may be
caused by heart failure and various types of shock. Assessment findings may
include low blood pressure; cool, clammy skin; weak, thready pulses; decreased
urinary output; and a diminished level of consciousness.
Risk for Infection
Many disorders may
place the client at risk for invasion by pathogenic organisms. Clients
receiving IV therapy are at risk for an infection because their primary
defense, the skin, is broken at the puncture site. Assessment findings
indicative of IV site infection are client complaints of soreness around site,
erythema, swelling at site, and foul-smelling discharge.
Impaired Oral Mucous Membrane
Altered oral mucous
membrane occurs when a client experiences disruption in the tissue layers of
the oral cavity. It is frequently related to dehydration. Assessment findings
may include: oral pain or discomfort; stomatitis; and decreased
salivation.
NURSING ALERT
Loss
of Gastric Juices
Clients who lose
excessive amounts of gastric juices, either through vomiting or suctioning, are
prone to develop not only DFV but also metabolic alkalosis, hypokalemia, and
hyponatremia; gastric juices contain hydrochloric acid, pepsinogen, potassium,
and sodium.
Deficient Knowledge
A knowledge deficit
may exist to varying degrees in clients with fluid imbalances. Information
obtained from a client’s health history may indicate the client’s level of
understanding and perception of these alterations and direct teaching. Clients
need to participate actively in their plan of care.
PLANNING AND OUTCOME
IDENTIFICATION
Holistic nursing care
for clients experiencing fluid imbalances requires that the nurse, in
collaboration with each client, identify specific goals for the nursing
diagnosis. These goals should be individualized to reflect the client’s
capabilities and limitations and should be appropriate to the diagnosis as
determined by the assessment data. During the planning phase, the nurse also
selects and prioritizes nursing interventions to support the client’s achievement
of expected outcomes based on the goals. For example, if vomiting and diarrhea,
with a weight loss of 5% and dry mucous membranes, led to a diagnosis of Deficient
Fluid Volume, then goals might include relief from vomiting and diarrhea
and achievement of the proper fluid balance of intake and output. Expected
outcomes for clients with fluid imbalances are not only specific to their
primary diagnosis but also require inclusion of outcomes relative to
interventions. An expected outcome for clients receiving IV therapy might read:
IV site remains free from erythema, edema, and purulent drainage, because
these clients are at risk for infection. Achievement of the goals and the
client’s expected outcomes indicates resolution of the problem.
IMPLEMENTATION
Nurses have the
responsibility to collaborate with and advocate for clients to assure that they
receive care that is appropriate, ethical, and based on practice standards.
Nurses rely heavily on the data obtained from the history in formulating
expected outcomes and selecting appropriate nursing interventions to support
the clients’ natural patterns as revealed in their history. The rationale for
interventions related to alterations in either body fluid or electrolytes is
based on the goal of maintaining homeostasis and regulating and maintaining
essential fluids and nutrients. The nurse capitalizes on the clients’ adaptive
capabilities by selecting interventions based on the clients’ perception of
their support, strengths, and options. Bulechek and McCloskey (1999) address
the importance of the nursing interventions relative to fluid therapy by
identifying the nurse’s responsibilities to:
• Understand the client’s metabolic needs and to make judgments concerning the outcomes of therapy
• Perform frequent assessment and monitoring to recognize the adverse effects
of fluid and electrolyte therapy and prevent complications
• Prevent the rapid depletion of the body’s protein and energy reserves
The nursing
activities relative to assessment and implementation often require the same
measurements: for example, weight and vital signs. Common interventions that
promote attainment of expected outcomes to restore and maintain homeostasis are
discussed next.
Monitor Daily Weight
Daily weight is one
of the main indicators of water and electrolyte balance. The nurse is
responsible for the accurate measurement and recording of daily weights; the
health care practitioner uses these data with other clinical findings in
determining the client’s fluid therapy.
Measure Vital Signs
The frequency of
measuring the vital signs is dependent upon the client’s acuity level and
clinical situation. For example, the vital signs of the typical postoperative
client might be taken every 15 minutes until stable, whereas a client
experiencing shock or hemorrhage should have vital signs monitored
continuously. Vital sign measurements and other clinical data are used to
determine the type and amount of fluid therapy.
Measure Intake and Output
Intake and output
measurements are initiated to monitor the client’s fluid status over a 24-hour
period (see Procedure 37-1 for information on how to measure the I&O).
Agency policy relative to I&O may vary with regard to:
• The time frames for charting (e.g., every 8 hours versus every 12 hours)
• The time at which the 24-hour totals are calculated
• The definition of “strict” I&O
“Strict” I&O
measurement usually involves accounting for incontinent urine, emesis, and
diaphoresis and might require weighing soiled bed linens. Don gloves before
handling soiled linen. The nurse reviews the client’s 24-hour I&O
calculations to evaluate fluid status. Intake should exceed the output by 500
ml to account for insensible body loses. I&O and daily weights are critical
components of intervention because these measurements are also used to evaluate
the effectiveness of diuretic or rehydration therapy.
Securing an accurate
I&O requires the full support of the client and his or her family. The
client and family members should be taught how to measure and record the intake
(see the accompanying display for special home health care considerations).
Provide Oral Hygiene
The nurse is
responsible for providing oral hygiene to promote client comfort and integrity
of the buccal cavity. Refer to Chapter 31 for the procedure on oral hygiene.
The frequency of oral hygiene depends on the condition of the client’s buccal
cavity and the type of fluid imbalance. A client who is dehydrated or NPO for
more than 24 hours may have decreased or absent salivation, coated tongue, and
furrows on the tongue. These clients are at risk for developing oral diseases
such as stomatitis, oral lesions or ulcers, and gingivitis.
Initiate Oral Fluid Therapy
Oral fluids may be
totally restricted—a situation commonly referred to as nothing by mouth (NPO,
which is from the Latin non per os)—or they may be restricted or forced,
depending on the client’s clinical situation. For example, oral replacement
therapy is often used for clients with mild dehydration. According to Hugger,
Harkless, and Rentschiler (1998), oral rehydration therapy has a very high
success rate in the treatment of childhood diarrhea with mild to moderate
dehydration, and it has fewer complications when compared to intravenous
replacement therapy. Severe dehydration in children is a medical emergency and
must be treated with intravenous replacement therapy.
Nothing by Mouth
Clients are placed
NPO status as prescribed by the health care practitioner. On the basis of
agency policy and clarification with the health care practitioner, the client may
be allowed small amounts of ice chips or medications with a sip of water when
NPO. Common clinical situations that may require NPO status include the need
to:
• Avoid aspiration in unconscious, perioperative, and preprocedural clients
who will receive anesthesia or conscious sedation
• Rest and heal the gastrointestinal (GI) tract in clients with severe
vomiting or diarrhea or when the client has a GI disorder (inflammation or
obstruction)
• Prevent the further loss of gastric juices in clients with nasogastric
suctioning NPO clients should receive oral hygiene every 1 to 2 hours or as needed for comfort
and to prevent alterations of the mucous membranes.
APPLICATION: HOME CARE
Considerations
for Measuring I&O
• Elicit client and family member input when selecting household items to be
used for intake measurement.
• Provide containers for measuring output; adapt the urinary container to
home facilities, and include teaching relative to proper washing and storage.
• Teach handwashing technique.
• Provide written instructions on what is to be measured.
• Provide sufficient I&O forms to last between the nurse’s visits.
• Identify the parameters for evaluating a discrepancy between the intake and
output and for notifying the nurse or health care practitioner.
NURSING ALERT
Remove Gloves before Charting
Remove gloves and wash hands before
recording the amount of drainage on the I&O form, to prevent the transfer
of microorganisms when the form is removed from the client’s room.
THINK ABOUT IT
Oral Hygiene
When you wake up in the morning, do you
drink or eat anything before brushing your teeth? If you were sick,
hospitalized, without family or significant other support, would you want to
drink or eat if your mouth tasted sour? Many of your clients will feel the same
way and will need supportive nursing care to maintain oral hygiene. Muscular
weakness and difficulty swallowing are other problems that could compound the
client’s dependency on you for oral hygiene.
NURS
I N G T I P
Mouthwashes
Avoid the use of alcohol and glycerin
mouthwashes and glycerin swabs. These ingredients may feel refreshing, but they
have a drying effect on the mucous membranes.
Restricted Fluids
Intake may be
restricted to 200 ml over a 24-hour period; intake is commonly restricted in
the treatment of EFV related to heart and renal failure. Client and family
teaching and collaboration are the main nursing interventions in implementing
this measure. How the nurse limits the fluids should be determined in
collaboration with the client. For example:
• Fifty percent of the allowed fluids might be taken at breakfast and lunch.
• The remaining 50% might be taken with the evening meal, before bedtime,
unless the client has to be awakened during the night for a medication.
Forced Fluids
Forcing or
encouraging the intake of oral fluids, mainly water, may be done when treating
elderly clients who are at risk for dehydration and clients with renal and
urinary problems, for example, kidney stones. Compliance is obtained by client
education and preference relative to timing and the type of liquids. A client
might, for example, be requested to consume 2,000 ml over a 24-hour time
period. If the client is intimidated on hearing this amount, which may sound
very large, explain that the number of glasses to which this volume equates is
only eight. Follow a similar time frame as set forth for restricted fluids,
with the largest quantity of fluids administered with meals. Ice, gelatin, and
ice cream count as liquid intake.
Maintain Tube Feeding
When the client
cannot ingest oral fluids and has a normal GI tract, fluids and nutrients can
be administered through a feeding tube as prescribed by a health care
practitioner. Refer to Chapter 38 for a complete discussion of feeding tubes.
Monitor Intravenous Therapy
When fluid losses are
severe or the client cannot tolerate oral or tube feedings, fluid volume is
replaced parenterally through the intravenous route. Intravenous (IV)
therapy is the administration of fluids, electrolytes, nutrients, or
medications by the venous route. The health care practitioner prescribes IV
therapy to treat or prevent fluid and electrolyte or nutritional imbalances.
The nurse has specific responsibilities relative to IV therapy (see the
accompanying Nursing Process Highlight). The Intravenous Nurses Society (INS)
is the professional organization that establishes standards of practice to
promote excellence in intravenous nursing to ensure the highest quality,
cost-effective care for all individuals requiring infusion therapies (INS, 2000).
INS standards of practice direct the development of agency policy/protocols in
accordance with state and federal regulations and should complement the
manufacturer’s direction for usage. The nurse should review the agency’s
protocols before gathering the equipment. IV therapy requires parenteral fluids
(solutions) and special equipment: administration set, IV pole, filter,
regulators to control IV flow rate, and an established venous route.
Parenteral Fluids
The nurse confirms
the type and amount of IV solution by reading the health care practitioner’s
prescription in the medical record. IV solutions are sterile and packaged in
plastic bags or glass containers. Solutions that are incompatible with plastic
are dispensed in glass containers. Plastic IV solution bags collapse under
atmospheric pressure to allow the solution to enter the infusion set. Plastic
solution bags are packaged with an outer plastic bag, which should remain
intact until the nurse prepares the solution for administration. When the plastic
solution bag is removed from its outer wrapper, the solution bag should be dry.
If the solution bag is wet, the nurse should not use the solution. The moisture
on the bag indicates that the integrity of the bag has been compromised and
that the solution cannot be considered sterile. The bag should be returned to
the dispensing department that issued the solution. Glass containers are
discussed in the section on equipment. IV solutions are usually packaged in
quantities ranging from 50 to 1,000 ml. The nurse should select a container
that has the prescribed amount of solution or select several containers that
together contain the prescribed volume. At no time should the nurse select a
container
Implementation of IV Therapy
• Know why the therapy is prescribed.
• Document client understanding.
• Select the appropriate equipment in accordance to agency policy.
• Obtain the correct solution as prescribed.
• Assess the client for allergies: tape, iodine, ointment, or antibiotic
preparations to be used for
skin preparation of
the venipuncture site.
• Administer the fluid at the prescribed rate.
• Observe for signs of infiltration (the seepage of substances into
the interstitial tissue that occurs as the results of accidental dislodgement
of the needle from the vein) and other complications that are fluid-specific.
• Document implementation of prescribed IV therapy in the client’s medical
record. whose volume is greater than that prescribed. For
example, if the client is to receive 600 ml of normal (0.9%) saline, the nurse
must not select a 1000 ml container, but rather two containers, 100 ml and 500
ml (containers are not prepared in volumes of 600 ml). Crystalloids (electrolyte
solutions with the potential to form crystals) are used to replace concurrent
losses of water, carbohydrates, and electrolytes. Sodium chloride and Ringer’s
lactate are commonly used crystalloid solutions. There are three types of
parenteral fluids that are classified in accord with the tonicity of the fluid
relative to normal blood plasma. As previously discussed, an osmolar solution
can be hypotonic, isotonic, or hypertonic. The type of solution is prescribed
on the basis of the client’s diagnosis and the goal of therapy. The normal
osmolarity of blood is between 280 and 295 mOsm/L, so the desired effect of the
tonicity of the fluid is determined as follows:
1. Hypotonic
fluid (hypo-osmolar, less than 290 mOsm/L) lowers the osmotic pressure and
causes fluid to move into the cells; if fluid is infused beyond the client’s
tolerance, water intoxication may result.
2. Isotonic
fluid (iso-osmolar, 290 mOsm/L) increases extracellular fluid volume; if fluid
is infused beyond the client’s tolerance, cardiac overload may result.
3. Hypertonic
fluid (hyperosmolar, greater than 290 mOsm/L) increases the osmotic pressure of
the blood plasma, drawing fluid from the cells; if fluid is infused beyond the
client’s tolerance, cellular dehydration may result (Bulechek & McCloskey,
1999). Table 37-5 discusses the common types of intravenous solutions in terms
of their tonicity, contents, and clinical usage. Crystalloid solutions can be
isotonic (equal to the sodium chloride concentration of blood, 0.9%); hypotonic
(less than the sodium chloride concentration of blood); and hypertonic (greater
than the sodium chloride concentration of blood) (Kee & Paulanka, 2000).
Colloids (nondiffusable substances) function like plasma proteins in blood by
exerting a colloidal pressure to replace intravascular volume only. Examples of
colloidal solutions are albumin, dextran, Plasmanate, and hetastarch
(artificial blood substitute). During the administration
of these solutions, the nurse should monitor the client for hypotension and
allergic reactions (Bulechek & McCloskey, 1999; Kee & Paulanka, 2000).
Blood transfusions are discussed later in this chapter.
Equipment
IV equipment is
sterile, disposable, and prepackaged with user instructions. The user
instructions are usually placed on the outside of the package, with a schematic
that labels the parts, allowing the user to read the package prior to opening.
The following discussion regarding intravenous equipment, inclusive of the
frequency when to change disposal intravenous therapy equipment, is based on
the revised 2000 Infusion Nursing Standards of Practice developed by
INS. All intravenous
equipment must be
inspected by the nurse to determine the integrity of the IV product before,
during, and after use. Product integrity refers to the sterility of the
equipment. Products are assessed for integrity by visual examination of the
product and checking the expiration date on the equipment. All products
identified with a defect must be returned to the appropriate department within
the agency with a written report identifying the defect. Since intravenous
therapy provides a direct access into the vascular system, the nurse must
understand the basic epidemiology principles and common organisms that may
cause an infection and implement infection control measures to minimize the
potential for infectious complications. The nurse uses aseptic technique and
standard precautions when assembling and changing intravenous equipment. To
decrease the risk of pathogen transmission, handwashing is required before and
immediately after all IV procedures and upon removal of gloves. The frequency
of changing sterile intravenous equipment not only reflects the national
standards of practice but the agency’s established infection control policies.
Infection control data may allow the agency to increase the time interval
beyond the recommended standard provided the data verifies low infection rates.
INS (2000) recommends that an organization that exhibits an increased rate of
catheter-related bloodstream infection with the practice of 72-hour
administration set changes should return to a 48-hour administration set change
interval.
Administration Set
The administration
set (infusion set) refers to the plastic disposal tubing that provides for the
infusion of a solution. There are several types of infusion sets to accommodate
the solution and the mode of administration: primary continuous; secondary;
primary intermittent; and special tubing for certain solutions such as
blood/blood components. There are several add-on devices, such as extension
sets, filters, stopcocks, PRN adaptor, and needleless devices that are used in
conjunction
with the
administration set and changed whenever the set is changed. Administration sets
are changed at established time intervals and immediately upon suspected
contamination or when the integrity of the set has been compromised. The
administration set contains an insertion spike with a protective cap, a drip
chamber, tubing with a slide clamp and regulating (roller) clamp, a rubber
injection port, and a protective cap over the needle adapter (Figure 37-10).
The protective caps keep
both ends of the
infusion set sterile and are removed only just before usage. The insertion
spike is inserted into the port of the IV solution container. Infusion sets can
be vented or nonvented. The nonvented type is used with plastic bags of IV
solutions and vented bottles. The vented set is used for glass containers that
are not vented (Figure 37-11). Glass containers require an air vent so that air
can displace fluid from the container into the IV tubing.
Some glass bottles are vented with an inside tube that
exits the bottle into a rubber stopper in the neck of the bottle; if the bottle
is not vented, then the nurse needs to select a vented infusion set. The drip
chamber is calibrated to allow a predictable amount of fluid to be delivered.
There are two types of drip chambers: a macrodrip, which delivers 10 to 20
drops per milliliter of solution, and a microdrip, which delivers 60 drops per
milliliter. The drip rate varies with the manufacturer as indicated on the
package. The administration set has a manual flow-control device such as a
slide clamp (Figure 37-10), a roller clamp, or a screw to regulate a prescribed
infusion rate. Follow the manufacturer’s guidelines when using the manual
flow-control device to regulate the prescribed infusion rate. The end of the IV
tubing contains a needle adapter that attaches to the sterile device inserted
in the client’s vein. Extension tubing may be used to lengthen the primary
tubing. A primary continuous administration set is used to administer routine
solutions prescribed to infuse continuously over a 24 hour period. The primary
administration set, inclusive of the add-on devices, is changed every 48 to 72
hours in conjunction with the peripheral cannula change. A bag of intravenous
solution should not hang longer than 24 hours. Secondary administration sets
are often referred to as “piggyback” administration sets. The secondary tubing
is connected into the primary tubing at an injection site (see Figure 37-11)
and allows for the administration of a second solution such as medication. Secondary administration sets are also changed every 48 to
72 hours. Primary intermittent administration sets are used to deliver
medications at prescribed intervals through an injection/access port and are
changed every 48 to 72 hours; all add-on devices such as extension sets,
filters, PRN adaptors, and stopcocks are changed with the intermittent
administration set. A sterile needle/ needleless device should be aseptically
attached to the intermittent administration set prior to administering the
medication and removed immediately after each use.
Health Hazard
A Health Alert from
Health Care Without Harm (HCWH) (1999) cautioned the public about the potential
risks of exposure to diethylhexyl phthalates (DEHP) from medical products such
as IV bags and tubing. More than 500 million IV bags are used in the United
States every year to deliver blood, medication, and other essential solutions
to clients (HCWH, 1999). Eighty percent of the IV bags are made with polyvinyl
chloride (PVC), which requires a plasticizer to make the bags soft and
flexible. DEHP is the softener used in PVC products. DEHP has been shown to
leach from IV bags into the solutions they contain and directly into the
client’s bloodstream. The Environmental Protection Agency has classified DEHP
as a probable human carcinogen and HCWH claims that studies have shown that
DEHP can damage the heart, liver, testes, and kidneys and interfere with sperm
production. Certain drugs such as Taxol (used to treat breast cancer) and
Taxotere (used to treat ovarian and breast cancer and AIDS-related Kaposi’s
sarcoma) have been shown to increase the leaching of DEHP from PVC plastics
into the solution (Stewart, 1999); see the accompanying display for additional
drugs that can increase leaching of DEHP from PVC IV products. Although one
leading producer of intravenous vinyl IV bags containing DEHP plans to develop
an alternative to polyvinyl chloride or PVC for their products, no time frames
were given to totally remove these products from the market. A second health
hazard is inherent in the use of DEHP. The disposal of medical products
containing DEHP releases highly toxic and endocrine-disrupting dioxins.
According to the ANA (1999), PVC is the only plastic linked both to phthalate
chemical leaching and to the production of dioxin.
Intravenous Filters
Intravenous filters
prevent the passage of undesirable substances such as particulate matter and
air from entering the vascular system. Particulate matter filters are utilized
when preparing infusion medications for administration to prevent obstruction
in the vascular/pulmonary systems, irritation and phlebitis (inflammation
of a vein). Aireliminating filters are used for the delivery of infusion
therapy to decrease the potential of air emboli; the filter should be located
as close as possible to the cannula site. IV filters come in various sizes; the
finer the filter, the greater is the degree of solution filtration. Although
studies have shown that IV filters reduce the risk of bacteremia and phlebitis
as much as 40%, some agencies do not use IV filters because of cost. Many IV
catheters contain an in-line filter; if the catheter has an in-line filter, it
is not necessary to add a filter to the tubing.
Needles and Venous
Peripheral-Short Catheters
Needles and
peripheral-short catheters provide access to the venous system. A variety of
devices are available in different sizes to complement the age of the client,
the type and duration of the therapy, and to protect the user from injury
(Figure 37-12). As with any gauge needle, the larger the number, the smaller
the lumen. The nurse considers the client’s age, body size, and the type of
solution to be administered when selecting the gauge of the needle or catheter:
• Infants and small children, 24 gauge
• Preschool through preteen, 24 or 22 gauge
DRUGS THAT INCREASE LEACHING
OF DEHP FROM PVC PLASTICS
• Chemotherapeutic agents: Etoposide (VePesid) and Teniposide (Vumon)
• Antianxiety agents: Chlordiazepoxide HCl (Librium)
• Antifungal agents: Miconazole (Monistat IV)
• Immunosuppressive agents: Cyclosporine (Sandimmune) and Tacrolimus
(Prograf)
• Nutritional solutions: Fat emulsions and vitamin A
NURS I N G T I P
Age
Considerations for Choosing IVs and Equipment
Neonates, infants,
and children are at risk for Altered Fluid Balance: Overload, related to
rehydration. IV tubing with a microdrip and special volume control chambers
is used to regulate the amount of fluid to be administered over a specific time
interval. Armboards and soft restraints are used to stabilize peripheral
infusions by immobilizing the extremity to prevent accidental removal of
infusion devices.
• Teenagers and adults, 22 or 20
gauge
• Geriatric, 22 or 24 gauge
Butterfly
(scalp vein or wing-tipped) needles are short,
beveled needles with plastic flaps attached to the shaft. The flaps (which are
flexible) are held tightly together to facilitate ease of insertion and then
flattened against the skin to prevent dislodgement during infusion. These
needles are commonly used for short-term or intermittent therapy and for
infants and children. There are several types of short catheters used to access
peripheral veins. Short peripheral venous catheters vary in length from 3/4 to
1 1/4 inches. During insertion, some of these catheters are threaded over a
needle, and others are threaded inside a
needle. Intracath is a term used to refer to a plastic tube inserted
into a vein. An angiocatheter is a type of intracath with a metal stylet
to pierce the skin and vein, after which the plastic catheter is threaded into
the vein and the metal stylet is removed, leaving only the plastic catheter in
the vein. Short venous catheters can have safety devices to reduce the risk of
accidental needlesticks. These devices are designed to allow for easy insertion
of the catheter while providing a built-in safety feature for the user. As the
catheter is threaded over the needle and advanced into the vein, the built-in
needle guard advances forward toward the tip of the needle; when the catheter
hub is removed from the device, the entire needle is encased within the needle
guard.
Peripheral Intravenous (PI) and Heparin Locks
Peripheral
intravenous (PI) and heparin locks are devices that establish a venous route as
a precautionary measure for clients
whose condition may change rapidly or who may require intermittent
infusion therapy. A butterfly needle or peripheral catheter is inserted into a
vein and the hub is capped with a lock port, also called a Luer lock (Figure
37-13).
Needle-Free System
Safety is a concern
associated with IV therapy; refer to Chapter 31. Accidental needle-stick
injuries and puncture wounds with contaminated devices increase the employee’s
risk for infectious diseases such as AIDS, hepatitis (B and C), and other viral,
rickettsial, bacterial, fungal, and parasitic infections. Most health care
agencies now use totally needle-free IV systems (Figure 37-14) to decrease the
risk of employee injuries.
Vascular Access Devices
Vascular access
devices (VAD) include various catheters, cannulas, and infusion ports that
allow for long-term IV therapy or repeated access to the central venous system.
The kind of VAD used depends on the client’s diagnosis and the type and length
of treatment (see Table 37-6). Site selection and insertion of central
catheters, other than peripherally inserted central catheters, is a medical act
performed by a practitioner. Although there are many types of catheter
materials, insertion techniques and kinds of central catheters, all central
catheters must be radiopaque to allow for radiographic verification of
placement of the catheter and its tip prior to the administration of any
solution. Central catheters are usually inserted into the internal jugular
and subclavian veins with the distal tip located in the superior vena cava to
minimize vessel irritation and sclerosis. The femoral vein can be used for
central venous access when there is thrombosis of the internal jugular or
subclavian veins; correct tip location should be in the inferior vena cava. Insertion
of a central catheter can be performed either percutaneously or surgically.
Surgically, a central catheter is either placed
N
edle
. An implantable
port is a device made of a radiopaque silicone catheter and a plastic or
stainless steel injection port with a self-sealing silicone-rubber septum. The
health care practitioner inserts the device into a subcutaneous pocket, usually
over the third or fourth rib, lateral to the sternum. The distal tip of the
catheter is surgically tunneled in the cephalic or external jugular vein, with
the proximal end of the catheter tunneled through the subcutaneous tissue into
the injection port of the device. Implanted ports and pumps are vascular access
devices that provide for the delivery of prescribed parenteral therapies.
Accessing these devices requires the use of aseptic technique. Noncoring
needles such as a Huber needle are used to access an implanted port/pump and
should be changed at least every 7 days. The smallest gauge noncoring needle
that can deliver the prescribed therapy should be used when accessing the
port/pump. Nurses caring for clients with implanted ports/pumps must have a
thorough knowledge of the design features of the device, as explained in the
manufacturer’s guidelines, to ensure correct access and administration
techniques, maintenance, and potential complications. Implanted pumps have a
reservoir designed to continuously infuse a specific volume of solution over a
preset period of time; the pump must be routinely emptied and refilled at
established intervals. Some pumps have an additional feature, a side port
designed for administration of intermittent medication. The flow rate of some
pumps is sensitive to changes in atmospheric pressure, body temperature, blood
pressure and the viscosity
of the medications. Clients are
instructed to report changes in their lifestyle and physical condition that may
affect the pump’s flow rate. Only nurses who have been specially trained are
allowed to access an implanted port/pump because of the risk of infiltration
into the tissue if needle placement is incorrect. A peripherally inserted
central catheter (PICC) is the
generic name for 11 different
devices. A PICC is a silicone or polyurethane catheter inserted into one of the
major veins in the antecubital fossa. Although the length of the catheter
varies, on an average a PICC is
of
registered nurses allow specially trained nurses to insert the PICC. Placement
of the catheter’s tip is confirmed by x-ray prior to the administration of any
solution. The registered nurse that inserts the PICC must document the type of
PICC inserted and the total length of the inserted catheter, and record if the
length of the catheter was trimmed prior to insertion.
Preparing an Intravenous Solution
To prepare an IV
solution, read the agency’s protocol and gather the necessary equipment.
Because IV equipment and solutions are sterile, check the expiration date on
the package prior to usage. The solution can be prepared at the nurses’ work
area or in the client’s room (Procedure 37-2). The nurse prepares and applies a
time strip to the IV solution bag to facilitate monitoring of the infusion rate
as prescribed by the health care practitioner (Figure 37- 19). The IV tubing is
tagged with the date and time to indicate when the tubing replacement is
necessary. IV tubing is changed every 48 to 72 hours in accord with the
agency’s protocol. The nurse initials the time strip and IV tubing tag.
NURSING ALERT
Marking
an IV Bag
Do not use a felt-tip
pen to mark an IV bag; the ink from the pen can leak through the plastic and
contaminate the solution. Do not label bag with time strip made of
adhesive/silk/paper tape, as the adhesive will leach into the bag. Use only
labels appropriate for IV bags.
Initiating IV Therapy
When initiating IV
therapy, the nurse should assess for a venipuncture site. Figure 37-20 presents
the common peripheral sites for starting IV therapy in pediatric, adult, and
geriatric clients (see Chapter 28, Procedure 28-1, Venipuncture). When
assessing clients for potential sites, consider their age, body size, clinical
status and impairments, and the skin condition (see the accompanying display
for contraindications when selecting a site). Lowerextremity veins are used for
IV therapy only when so prescribed by the health care practitioner;
circulating
Figure
37-20 Peripheral Veins Used in Intravenous Therapy.
A. Armand Forearm; B. Dorsum of the Hand; C. Dorsal Plexus of the Foot
blood in the lower
extremities is likely to pool and clot, which may result in an embolism.
Because contact with blood is likely, venipuncture requires the implementation
of Standard Precautions. Refer to Chapter 31 for a complete discussion of
Standard Precautions. Select a vein for puncture at its most distal end to
maintain the integrity of the vein, because venous blood flows with an upward
movement toward the heart. When a vein is punctured with an instrument, such as
a needle, fluids can infiltrate (leak from the vein into the tissue at the site
of puncture). If IV therapy has to be discontinued for any reason, such as
infiltration, it can be restarted above the initial puncture site only.
Vein Finder
A vein finder is a
device used to locate hard-to-find veins. It is helpful, for example, in working
with obese clients whose superficial veins are difficult to locate. A Venoscope
(Figure 37-21) is a type of vein finder with adjustable fiberoptic arms that
reveal veins. The room is dimmed, and the disposable skids are placed flush
against the skin. The nurse slowly moves the Venoscope along the extremity
until a dark, shadowy line is seen between the fiberoptic arms. Once the vein
is identified, it can also be checked to determine whether it is sclerotic. To
assess for sclerotic veins, apply a downward pressure over the fiberoptic arms
and observe the vein when pressure is applied then released. A nonsclerotic
vein will disappear with pressure and reappear when pressure is released.
Administering IV Therapy
Once the solution is
prepared for administration, the nurse calculates the rate and explains the
procedure to the client (see Procedure 37-3 for the administration of IV
therapy). There are three ways to administer solutions:
1. Initiate the infusion by performing a venipuncture.
2. Use an existing IV system: catheter, heparin or PI lock, central line, or
implanted port.
3. Add a solution to a continuous-infusion line.
Fluid administration can be continuous, ongoing over a 24-hour
period, or intermittent, 1000 ml ordered once in a 24-hour period. Although
fluids may be continuous, the type of fluids can alternate over a 24-hour
period; for example, an order might be add 40 mEq of KCl to first bag of
1000 ml of normal saline. IV medications may be piggybacked, added
to an existing intravenous solution to infuse concurrently. IV solutions and
medications that have been refrigerated should
Flushing
Flushing refers to
the instillation of a solution into an intravenous cannula. Flushing is
performed to assess and maintain cannula patency and prevent the mixing of
incompatible medications and/or solutions, following the conversion of
continuous IV therapy to intermittent IV therapy, and to maintain intermittent
cannula patency following IV medication administration and blood sampling. The
type of solution and frequency of flushing an intermittent intravenous cannula
is determined by the agency’s policy/protocol. According to the INS (2000),
flushing a cannula at established intervals with saline (0.9% sodium chloride
injection) is the accepted solution to ensure and maintain patency of an
intermittent PI cannula, while a heparin flush solution is the accepted
solution to maintain patency of an intermittent central venous devices. The
volume of flush is equal to the volume capacity of the cannula and add-on
devices times two (INS, 2000). Consideration is also given to the volume and
frequency of heparin flush in order to prevent an alteration in the client’s
clotting factors. When flushing a cannula positive pressure within the lumen of
the catheter must be maintained to prevent the reflex of blood into the cannula
lumen. Use the manufacturer recommended maximum pressure limits (pounds per
square inch) when selecting the size of the syringe to use for flushing since
the smaller the syringe the greater the pressure generated; excessive internal
pressures in the device increase the potential for cannula damage and/or
progressive internal cannula weakening over the life of the device (INS, 2000).
If resistance is met when flushing a cannula, do not exert pressure in an
attempt to restore patency of an occluded cannula since this action may result in the dislodgement of
a clot into the vascular system and/or rupture of the catheter.
Regulating IV Solution Flow Rates
Infusion sets with
macrodrip chambers are often used for adult clients, whereas microdrip chambers
are used for volume-sensitive clients, such as geriatric or pediatric clients.
Pediatric and geriatric clients usually require some type of device to regulate
the fluids as a safety factor to prevent overload. Devices such as controllers
and pumps are commonly used to regulate the rate of infusion.
Calculation of Flow Rate
The flow rate is
the volume of fluid to infuse over a set period of time as prescribed by the
health care practitioner. The health care practitioner will identify either the
amount to infuse per hour (such as 125 ml per hour or 1000 ml over an 8-hour
period). Calculate the hourly infusion rate as follows: For example, if 1000 ml
is to infuse over 8 hours: Calculate the actual infusion rate (drops per
minute) as follows: For example, if 1000 ml is to infuse over 8 hours with a
tubing drop factor of 10 drops per milliliter: Another way to calculate the
actual infusion rate is to use the hourly infusion rate; for the example just
given:
Flow-Control Devices
Flow-control devices
are used to regulate the infusion at the prescribed administration rate. Safety
factors such as the client’s age and condition, prescribed therapy, and setting
are considered when selecting a flow-control device. There are two basic types
of flow-control devices: manual flow-control devices and electronic infusion
devices. Manual flow-control devices include roller, screw, and slide clamps
and may include volume control devices such as Buretrol. These devices are used
routinely to regulate the accurate delivery of most prescribed IV therapy.
Electronic infusion devices are operated either by electricity or battery and
are used to administer IV fluids and medications and should be considered on
all central access devices (INS, 2000). Electronic infusion pumps have audible
alarms that sound when the solution has infused, the infusion tubing contains
air or is kinked, or the cannula is clotted. There are two types of electronic
infusion devices: controllers and pumps. Controller infusion devices generate
flow by gravity and are capable of maintaining a constant preset flow rate
either by drop counting or volumetric delivery. The nurse sets the flow rate,
and the specific gravity of the solution and the height of the bag determine
the maximum delivery pressure. Fluids with low-viscosity are usually infused by
electronic controllers. Infusion pumps maintain the flow rate under positive
pressure. Pumps counter the effects of resistance in the delivery system and
pressure fluctuations at the infusion site (McConnell, 1999). Positive pressure
infusion
devices are
classified as either volumetric or syringe pumps, and are used to deliver
viscous fluids or large volumes of fluids. Volumetric pumps use either a
peristaltic pumping action or a pumping cassette or chamber to delivery a fixed
volume over a specified period of time. Syringe infusion pumps rely on a
syringe or cartridge to deliver the fluid at a specific set rate.
Managing IV Therapy
IV therapy requires
frequent client monitoring by the nurse to ensure an accurate flow rate and
other critical nursing actions; refer to Procedure 37-4. These other actions
include ensuring client comfort and positioning; checking IV solution for
correct solution, amount, and timing; monitoring expiration dates of the IV
system (tubing, venipuncture site, dressing) and changing as necessary; and
being aware of safety factors. Coordinate client care with the maintenance of
IV lines. Clients with IV therapy usually require assistance with hygienic
measures, such as changing a gown (see Procedure 37-4). Change IV tubing when
doing site care to decrease the number of times the access device is manipulated, thereby decreasing the risk for
infiltration and phlebitis. PI devices are changed every 72 hours as directed
by the Centers for Disease Control and
Prevention (CDC)
guidelines.
Hypervolemia
Hypervolemia
(increased circulating fluid volume) may result from
rapid IV infusion of solutions. This causes cardiac overload, which may lead to
pulmonary edema and cardiac failure. Monitor the infusion rate hourly and refer
to the Nursing Care Plan, Client with Fluid Volume Excess, for the assessment
and interventions for a client experiencing fluid volume excess. Total volume
Number of hours to infuse = ml/hour
infusion rate 1000 8 = 125 ml/hour
Total fluid volume
Total time (minutes) drop factor = drops per minute
1000 ml
8(60) min10
drops/ml =
10,000 drops
480 min = 20.8 or 21
drops/min
125 ml 10
drops/ml
60 min
= 20.8 or 21 drops/min
NURSING ALERT
Catheter
Sepsis
If client complains
of chills and fever, check length of time that this IV solution has been
hanging and the needle or catheter has been in place; assess client’s vital
signs, and assess for other symptoms of pyrogenic reactions, such as backache,
headache, malaise, nausea, and vomiting. Unexplained fever may be related to
catheter sepsis. Pulse rate increases and temperature is usually above
If a solution infuses at a rate greater than
prescribed, decrease the rate to keep
vein open (KVO) and immediately notify the health care practitioner. Report
the amount and type of solution that infused over the exact time period and the
client’s response.
Infiltration
Infiltration may be
caused by inserting the wrong type of device, using the wrong-gauge needle, or
dislodgement of the device from the vein. When a drug or solution is
administered under high pressure by a pump, it may also cause infiltration or
vein irritation. Infiltration results in the leaking of fluids or medications
into the surrounding tissue. The client usually complains of discomfort at the
IV site. Inspect the site by palpating for swelling, and feel the temperature
of the skin (coolness and paleness of skin are indications of infiltration).
The nurse confirms that the needle is still in the vein by pinching the IV
tubing; this action should cause a flashback (blood should rush into the
tubing if the needle is still in the vein). If a flashback does not occur,
aspirate the injection port nearest the device as explained in Procedure 37-4.
Discontinue the needle or catheter if it cannot be aspirated and apply a
sterile dressing to the puncture site. After the IV has been removed, the
puncture site may ooze or bleed (especially in clients receiving
anticoagulants). If oozing or bleeding occurs, apply pressure and reapply a
sterile dressing until it stops. Accurately assess and document the degree of
edema. Clients may be injured by infiltration. If the IV site becomes grossly
infiltrated, the edema in the soft tissue may cause a nerve compression injury
with permanent loss of function to the extremity. If a vesicant (medication
that causes blistering and tissue injury when it escapes into surrounding
tissue) infiltrates, it may cause significant tissue loss with permanent
disfigurement and loss of function.
Phlebitis
Phlebitis may result
from either mechanical or chemical trauma. Mechanical trauma may be caused by
inserting a device with too large a gauge, using a vein that is too small or
fragile, or leaving the device in place for too long. Chemical trauma may
result from infusing too rapidly, or from an acidic solution, hypertonic
solution, a solution that contains electrolytes (especially potassium and
magnesium), or other medications. Phlebitis may be a precursor of sepsis.
Listen for client complaints of tenderness, the first indication of an
inflammation. Inspect the IV site for changes in skin color and temperature (a
reddened area or pink or red stripe along the vein, warmth, and swelling are
indications of phlebitis). If phlebitis is present, discontinue the IV
infusion. Before removing and discarding the venous device, check the agency’s
protocol to see whether the tip of the device needs to be cultured and sent to
the laboratory for a culture and sensitivity. After removing the device, apply
a sterile dressing to the site and wet warm compresses to the affected area. Document
in the nurses’ notes the time, symptoms, and nursing interventions. Hypertonic
solutions may cause irritation necessitating frequent IV site changes. Observe
site for symptoms of postinfusion phlebitis following IV removal. This may
occur in response to either chemical or mechanical factors of the preexisting
IV. Postinfusion phlebitis is treated with hot compresses to the site and
elevation of the extremity.
Intravenous Dressing Change
IV dressing changes
require the use of Standard Precautions and aseptic technique; refer to
Procedure 37-4. Institutional protocol and the type of intravenous access
device and dressing determine the frequency of care:
1. Nontransparent (gauze) dressing may be used for a PI. It is changed every
24 hours.
2. Transparent dressings (Bioclusive, OpSite, Tegaderm) allow visualization of
the IV site; these dressings are changed every 48 hours. Persistent drainage at
the IV site may require dressing changes more frequently or necessitate
changing the IV site.
Discontinuation
of Intravenous Therapy
Intravenous therapy
is discontinued on health care practitioner order as determined by the client’s
need or response to therapy. The removal of a short peripheral catheter is a
nursing intervention to minimize the complication risks related to infusion
therapy or to implement the health care practitioner’s order. Peripheral
catheters are removed every 48 hours and immediately upon suspected
contamination or complications. Pressure and a dry sterile dressing are applied
to the site upon removal of the catheter; refer to Procedure 37-4. The
integrity of the catheter and insertion site should be assessed with
observations and actions documented to the client’s medical record. The removal
of a PICC is usually a simple procedure; however, research suggests that, in 7%
to 12% of PICC removals, difficulties can arise (Macklin, 2000). Only nurses
who have been trained in the insertion of a PICC line should remove the
catheter. Since the catheter is completely inserted in the vascular system and
invisible, the nurse must feel for resistance during removal. If resistance is
felt, the nurse stops and assesses for certain complicating factors: venous
spasm, vagal reaction, phlebitis, thrombosis, and knotting of the catheter.
Prior to removal, the nurse must verify in the client’s medical record the type
and the specific length of the inserted PICC.
Blood Transfusion
The purpose of a
blood transfusion is to replace blood loss (deficit) with whole blood or blood
components.
NURSING ALERT
IVs
and the Critically Ill
Never remove a
functioning intravenous device from a critically ill client until another
successful venipuncture has been performed; an established intravenous route
may be needed for the administration of solutions, medications, or blood components.
NURS I N G T I P
Phlebitis
Tenderness, not
redness, is the earliest sign of peripheral IV-site phlebitis. administer,
either whole blood or a component of whole blood, such as packed red blood
cells.
Whole Blood and Blood Products
Clients with a
demonstrated deficiency in either whole blood or a specific component of blood
are given a blood transfusion. Whole blood contains red blood cells (RBCs) and
plasma components of blood. It is used when the client needs all the components
of blood to restore blood volume after
severe hemorrhage and to restore the capacity of the blood to carry oxygen.
Various types of blood components are used in the clinical setting (Table
37-7). Packed RBCs are more commonly prescribed than whole blood. Plasma or fresh
frozen plasma is separated and frozen within 8 hours after blood collection. Albumin (protein colloid) is a
volume expander that maintains the colloid osmotic pressure of the blood.
Albumin, hetastarch, and dextran (nonprotein colloids) are agents that increase
intravascular volume in order to maintain hemodynamic stability and to provide
adequate tissue perfusion. Cryoprecipitate is the most expensive of all blood
components because it is constituted from many units of whole blood. When the
health care practitioner prescribes the administration of whole blood or a
blood product, the client’s blood is typed and crossmatched; refer to Chapter
28 for a complete discussion of blood groups and Rhesus (Rh) factor. Check with
the family for donors if time and the client’s condition permit. The blood is
stored in the blood bank after typing and crossmatching until the nurse is
ready to administer.
Although whole blood
has a refrigerated shelf life of 35 days, platelets must be administered within
3 days after they have been extracted from whole blood. If the RBCs and plasma
are frozen, their shelf life can be extended up to 3 years (Kee & Paulanka,
2000).
Initial Assessment and Preparation
The nurse must
perform an initial assessment before administering blood (see the accompanying
display). The viscosity of whole blood usually requires the use of an 18- or
19-gauge needle or catheter to prevent damage to the red cells.
BLOOD TRANSFUSION,
INITIAL ASSESSMENT
• Verify that client has signed a blood administration consent form and that
this consent matches what the health care practitioner has prescribed.
• Verify whether the client has an 18- or 19-gauge needle or catheter in the
vein; if the blood is to be infused quickly, a 14- or 15-gauge device must be
used. Pediatric and elderly clients may require a 23- gauge device because of
smaller or thin-walled veins.
• Ensure patency of the existing IV site.
• Establish baseline data for vital signs, especially temperature, and assess
skin for eruptions or rashes.
• Check client’s blood type against the label on the whole blood or blood
component prior to administration, to ensure compatibility.
• Assess client’s age. If the client is at risk for circulatory overload
(pediatric, elderly, or malnourished clients), notify the blood bank to divide
the 500-ml bag of blood into two 250-ml bags or discuss with the health care
practitioner other alternatives, such as packed RBCs rather than whole blood.
Scheduled IV medications should be infused before
blood administration. This sequence prevents a reaction to a medication while
blood is infusing; if a reaction were to occur, the nurse would not be able to
discern which infusate was causing the reaction.
Administering Whole Blood or a Blood Component
The agency’s blood
protocol may require that a licensed person sign a form to release the blood
from the blood bank and that a blood product be checked by two licensed
personnel prior to infusion. The following information must be on the blood bag
label and verified for accuracy: the client’s name and identification number,
ABO group and Rh factor, donor number, type of product ordered by the
practitioner, and the expiration date. Observe the blood bag for any signs of
puncture, gas bubbles, color, and consistency (RBCs clumping). When the
information has been verified, both licensed personnel sign the appropriate
form. If any of the information does not match exactly or if the product has
expired, return the product immediately to the blood bank. Blood should be
administered within 30 minutes after it has been received from the bank, to
maintain RBC integrity and to decrease the chance of infection. Whole blood
should not go unrefrigerated for more than 4 hours. Room temperature will cause
RBC lysis, releasing potassium and causing hyperkalemia (Procedure 37-5).
Safety Measures
As discussed in Procedure 37-5, the
client should be observed for the initial 15 minutes for a transfusion
reaction. Vital signs are usually taken every 15 minutes for the first hour,
then every hour while the blood is transfusing. To prevent blood contamination,
change the blood tubing and filter every 4 hours or after each unit of blood.
Transfuse each unit of blood over a 2- to 4-hour interval.
NURSING ALERT
Transfusion Reaction
The severity of a transfusion reaction
is relative to its onset. Severe reactions may occur shortly after the blood
starts to infuse. At the first sign of a reaction, stop the blood infusion
immediately.
NURSING ALERT
Blood Transfusion Incompatibility
Use only normal saline with a blood
product. Blood transfusions are incompatible with dextrose and with Ringer’s
solution. Together, they cause hemolysis, clumping of RBCs.
As a
precaution against a blood transfusion reaction, prepare a bag of normal
saline, as directed by protocol. The normal saline is prepared as a secondary
infusion system; it should not be connected to the Y-set tubing that is
transfusing blood. If the client has a reaction, and the blood is discontinued,
the secondary bag of normal saline should be connected and infused. This action
prevents the client from receiving all the blood that is in the Y-set tubing,
approximately 20 to 30 ml. Even though the procedure for infusing packed cells,
and sometimes whole blood, requires a Y-set for coadministering normal saline,
the secondary bag of normal saline is a precautionary measure for transfusion
reactions. There are three basic types of transfusion reactions: allergic,
febrile, and hemolytic. Other complications include sepsis, hypervolemia, and
hypothermia. An allergic reaction may be mild or severe, depending on the
cause. Hemolytic reactions may be immediate or
delayed up to 96 hours, depending
on the cause of the reaction. The classic symptoms of a reaction and sepsis are
fever and chills. The immediate nursing actions for all types of reactions and
complications are: stop the transfusion, keep the vein open with normal saline,
and notify the health care practitioner. Other measures include sending the IV
tubing and bag of blood back to the blood bank; obtaining a blood and urine
specimen; labeling the specimen “Blood Transfusion Reaction”; processing a
transfusion reaction report; monitoring vital signs every 15 minutes for 4
hours or until stable; and monitoring the intake and output. A delayed
hemolytic reaction results when the donor and client’s anti-A or anti-B
agglutinins are mismatched or when there has been improper storage of the blood
unit. This reaction causes the cells to clump and form plugs in small blood
vessels. Within a few hours or days, the phagocytic WBCs and the
reticuloendothelial sys- tem destroy agglutinated cells, releasing hemoglobin
into the plasma. The client is monitored for jaundice, persistent anemia or
fever, oliguria, flank pain, and abnormal bleeding. An immediate hemolytic reaction
is a rare occurrence. It results from a mismatch of donor and client’s blood,
causing immediate hemolysis of RBCs. The antibodies cause lysis of RBCs, which
release proteolytic enzymes that rupture the cell membranes. The clinical
manifestation are headache, dyspnea, cyanosis, chest pain, and tachycardia.
Febrile reactions are common and result from the client’s sensitivity to WBCs,
platelets, or plasma proteins. Warm, flushed skin, headache, muscle pain, and
anxiety are the symptoms of a febrile reaction. It is treated with antipyretic
medication. To help prevent a febrile reaction, keep the client warm during the
transfusion. Make sure that the tubing has a leukocyte-reduction filter. The
leukocyte-reduction filters also reduces the risk of transmitting cytomegalovirus
(CMV) (a DNA virus that causes intranuclear and intracytoplasmic changes in
infected cells). Approximately 10% of
seropositive donors are capable of transmitting CMV infection. Mild allergic
reactions are common, resulting from a sensitivity to infusing plasma proteins.
Allergic reactions cause a rash, itching, hives (urticaria), and wheezing.
Clients with these symptoms should be monitored for anaphylactic shock.
Antihistamines may be prescribed to counter the allergic response. Severe
allergic reaction results from an antibody-antigen response as demonstrated by
shortness of breath and chest pain; if untreated, it may cause circulatory
collapse and cardiac arrest. If this occurs, initiate CPR after the blood has
been discontinued. Sepsis results from the administration of contaminated blood
(containing gram-negative bacteria). It is a serious complication. Clinical
manifestations include chills and fever, vomiting, abdominal cramping,
diarrhea, shock, and renal failure. It is treated with broadspectrum
antibiotics and steroids. Nursing measures are
directed toward maintaining
hydration and monitoring intake and output to evaluate renal function.
Hypervolemia from fluid overload is a preventable complication. Clients at risk
for FVE are placed in a sitting position. The blood is transfused at a reduced
flow rate; request the blood laboratory to divide the unit into 2 containers of
blood so that none of it is unrefrigerated for more than 2 hours during
transfusion. Clinical manifestations of hypervolemia are similar to those of
FVE
(dyspnea, cough and rales,
distended neck veins, hypertension, tachycardia, and pulmonary edema).
Administer oxygen and IV diuretics as prescribed to treat circulatory overload.
Clients needing rapid transfusions are at risk for transfusion-induced
hypothermia. Such clients may include neonates needing exchange-transfusions
and trauma victims who require large volumes of whole blood. A blood-warming
device may be prescribed to prevent transfusion-induced hypothermia. The
symptoms of transfusion- induced hypothermia result from the rapid transfusion
of large amounts of cold blood. If the infusing blood temperature is below