LPN-C

1. LPN-C Unit Four Rationale for Intravenous Therapy

2. What is the Purpose ofIntravenous Therapy? • Maintenance • Water • Glucose • Protein • Vitamins • Electrolytes • pH • Restoration of previous losses • Replacement of present losses • Administration of medication

3. Water Water is necessary for adequate kidney function – Normal Intake Normal Output Oral liquids 1300mL Urine 1500mL Water in food 1000mL Stool 200mL Metabolism 300mL Lungs 300mL Total 2600mL Skin 600mL Total 2600mL • Individual fluid requirements vary • Total body water percentage is higher in infants (80% compared to 60% in adults) • Infants require more water than older children or adults • Infants are more vulnerable to fluid volume deficit

4. Glucose • Converted to glycogen by the liver • Has 4 main uses in parenteral therapy • Improves hepatic function • Supplies the necessary calories for energy • Spares body protein • Minimizes ketosis • Approximately 100 – 150g of glucose is needed daily to minimize protein catabolism • 1 liter of 5% dextrose in water supplies 50g of glucose • Dextrose in water is available in 2.5%, 5%, 10%, 20%, and 30%

5. Glucose (cont’d) • Dextrose concentrations higher than 10% must be given through a central vein • The exception is 50% dextrose slow IV push at a rate of 3mL/min through a peripheral vein for emergency treatment of hypoglycemia Protein • Amino acids are the building blocks of the body • Tissue growth and repair • Wound healing • Available in concentrations of 3.5 – 15% • Used in TPN centrally and peripherally

6. Protein (cont’d) • Daily requirements = 1g protein/kg body weight • Amount increases as stress to the body increases • Gluconeogenesis = conversion of protein to glucose to meet energy requirements • Occurs during starvation, stress, or infection • Uses large amount of energy • Body will use protein for energy if there are inadequate glucose stores

7. Vitamins • Vitamins B and C are most frequently used • Vitamin B is needed for the metabolism of carbohydrates and maintenance of GI function • Vitamin C promotes wound healing Electrolytes • Correction of electrolyte imbalances is important in preventing serious complications • Important in parenteral therapy • Potassium, sodium, chloride, magnesium, phosphorus, calcium, bicarbonate

8. Electrolytes (cont’d) • Potassium • Adequate replacement therapy = 20mEq/L • Patients who need potassium replacement – • Stress from tissue injury • Wound infection • Gastric or bowel surgery • Prolonged gastric suction • Assess renal function prior to potassium replacement • Excreted through the urine • Intoxication can occur rapidly and with no symptoms • Slow rate of infusion • no more than 20mEq/L per hour via peripheral line • no more than 40mEq/L per hour via central line • Never give potassium via IV push • Always use a cardiac monitor with K+ infusion

9. Electrolytes (cont’d) • Potassium (cont’d) -- • Infiltration of potassium is extremely irritating to the tissue • Can cause necrosis • Imperative to use extravasation protocol • In the case of infiltration, discontinue the infusion, apply cool compresses, and elevate the extremity by 4 inches pH • Most IV solutions are acidic • Allows for longer shelf life • The more acidic a solution, the more irritating to the vein

10. Parenteral Nutrition • Peripheral venous delivery of parenteral nutrition (PPN) • Glucose concentration is not to exceed 10% • Usually utilized for 3 – 7 days • Assess for metabolic abnormalities • Hyperglycemia • Most common metabolic abnormality in PPN • Rapid administration of fluid • Increased levels of stress hormones • Hypoglycemia can occur if infusion is discontinued abruptly • Hypokalemia • Insulin-related shift of potassium from the extracellular compartment to the intracellular compartment

11. Fluid Balance in Infants and Children • More vulnerable to fluid volume deficit • Kidneys are immature up to 2 years of age • Cannot conserve or excrete water or sodium in response to imbalances as efficiently as adults • Body surface area in infants is larger than in adults per size • Lose more fluid through the skin • Infants have a higher metabolism rate which requires more water per size • Produce more heat than adults • Larger amount of metabolic waste to secrete • Less stable regulatory responses to fluid imbalances

12. Fluid Balance/Infants/Children (cont’d) • Fevers are higher and last longer in acute illness • Increases fluid loss • Symptoms of fluid imbalance • Decreased appetite • Less active • More irritable • Flaccid appearance • Diarrhea, vomiting • Decrease in voiding • Nursing assessment • Assess concentration of urine

13. Fluid Balance/Infants/Children (cont’d) • Nursing assessment (cont’d) -- • Weigh diapers • Monitor for diarrhea • Common cause of isotonic dehydration • Proportionate loss of water and electrolytes • Formula containing an inappropriately high amount of solute can cause diarrhea that leads to hypertonic dehydration • Greater loss of water than electrolytes • Monitor for weight changes • Record weight before onset of illness • Physician’s records • Parent/family/caregiver report • Weight loss resulting from fluid volume deficit is more rapid than with loss of body mass

14. Fluid Balance/Infants/Children (cont’d) • Nursing assessment (cont’d) – • Monitor vital signs • Blood pressure is not always reliable because elasticity of the blood vessels in children keeps blood pressure stable initially • Tissue turgor • Skin remains slightly raised for a few seconds with fluid volume deficit • Skin turgor begins to decrease after 3-5% body weight is lost as fluid • Obese infants/children have deceptive skin turgor • Normal in appearance in spite of fluid volume deficit

15. Fluid Balance in the Elderly • At risk for fluid volume deficit due to normal aging changes • 6% reduction of total body water • Decrease in ratio of intracellular fluid to ECF • Loss of 30-50% glomeruli by the age of 70 • Decrease in glomerular filtration rate • Decreased ability to concentrate urine • Decreased secretion of aldosterone • Decrease in the response of the distal tubule to ADH • Decrease in glucose tolerance • Decreased sensation of thirst • Decreased skin elasticity • Poor indication of turgor • Atrophy of the sweat glands

16. Fluid Balance in the Elderly (cont’d) • Normal aging changes (cont’d) -- • Diminished capillary bed • Less effective cooling of body temperature • Decreased cardiac output • Increased risk for orthostatic hypotension • Increased risk for falls • Decreased elasticity of arteries • Immediately assess fluid status with any changes in mental status • Typical assessment findings • Dehydration frequently seen • Normal body temperature lower (97°F) • Mucus membranes less moist • Positional changes in blood pressure common

17. Fluid Balance in the Elderly (cont’d) • Typical assessment findings (cont’d) – • Most accurate assessment of skin turgor is over the sternum • Special problems in the elderly • Hypernatremia • Common problem in LTC facilities • Immobility • Unable to express thirst • Reduced motility of GI tract • Laxative dependency • Heat stroke • Elderly more susceptible • Decreased efficacy of sweat glands • Normal temperature decreases with age • Temperature of 99°F would be high for the body

18. Fluid Balance in the Elderly (cont’d) • Special problems (cont’d) -- • Radiocontrast agents (IVP) • High in sodium • Difficulty excreting due to ↓ glomerular filtration rate • Preoperative concerns • Administration of adequate IV fluids before surgery • Improves renal blood flow and renal function • Minimum urine output should be 50mL/hour • High risk for hypothermia in the operating room • Cool fluids, cool environment, etc. • Diminished respiratory function interferes with elimination of carbon dioxide • Leads to respiratory acidosis • Achieve maximum ventilation through suction, turning, activity

19. Fluid Balance in the Elderly (cont’d) Special problems (cont’d) -- • Preparation for diagnostic tests • Bowel cleansing • NPO status Diet and Lifestyle Factors Affecting Fluid Balance • Difficulty chewing or swallowing • Inadequate food/fluid intake • Malnutrition/starvation • Low protein intake; altered fluid volume status • Excessive alcohol consumption • Liver damage leading to fluid/electrolyte imbalance

20. Environmental Factors & Fluid Balance • Vigorous exercise increases metabolism, ventilation, sweating • Increases fluid demand • Potential lack of fluid intake • Heat injuries • Exposure to hot, humid environments increases sweat production to as much as 2L/hour • Body fluid weight loss >7% is associated with failure of body cooling mechanisms Medications Altering Fluid Balance • Diuretics = excessive fluid loss • Chemotherapy = nausea/vomiting, poor oral intake

21. Fluid Needs for Those with Acute Illness • Surgery can result in blood and fluid loss • Gastroenteritis causes nausea/vomiting and diarrhea • Nasogastric suctioning leads to fluid and electrolyte losses • Brain injury from stroke, trauma, or tumor • Causes cerebral edema, which may put pressure on the hypothalamus and/or pituitary • Alters ADH • SIADH • Diabetes insipidus • Excessive or inadequate ADH production/release • Burns

22. Burns • Factors affecting fluid loss -- • Surface area • The larger the burn, the greater the fluid loss • Extent, depth, and cause of the burn • Age of the client • Pre-existing medical conditions • Diagnostic findings – • WBC reflects immune function • Hgb/HCT increases due to fluid loss • Glucose increases due to stress response • Sodium decreases (trapped in third spaces) • Potassium increases due to tissue destruction

23. Burns (cont’d) • Third space fluid shifts -- • Phase I → plasma to interstitial space • Occurs rapidly (before the end of the 1st hour) • Plasma leaks out through damaged capillaries at the burn area • Edema forms • Hypovolemia occurs (may lead to acute tubular necrosis) • Decreased renal perfusion • Low urine output • Hyperkalemia • Fluid accumulation phase occurs during the first 36 to 48 hours • Capillaries have recovered by the end of this time

24. Burns (cont’d) • Third space fluid shifts (cont’d) -- • Phase II → fluid remobilization • Begins approximately 48 hours after burn occurs • Edema at burn site resolving • Hypervolemia due to fluid shifting back into the intravascular compartment • Metabolic acidosis due to accumulation of acids released from the injured tissue • Respiratory acidosis due to inhalation injury that interferes with gas exchange • Nursing assessment – • Rule of Nines • Lund-Browder Chart

27. Burns (cont’d) • Treatment -- • Aggressive fluid replacement is necessary to prevent complications • Need to induce urine output at 1cc/kg/hour • Use large bore IV in a peripheral vein in an area that is unaffected by burn injury • 2nd choice = central line in an unaffected area • 3rd choice = peripheral line in an affected area • Last choice = central line in an affected area • Monitor for IV-related sepsis • Foley catheter placement • Early burn wound excision • Timely initiation of enteral nutrition

28. Fluid Needs for Those with Chronic Illness • Liver disease decreases production of albumin, which affects the ability to maintain vascular volume • Renal disease limits the ability to regulate fluid or electrolytes via urine output • Diabetes increases the risk for hyperglycemia and hypertonic dehydration • Cancer treatment (chemotherapy) induces nausea/vomiting with fluid loss and decreased intake

29. Diabetic Ketoacidosis (DKA) • Occurs in 2 – 5% of people with Type I Diabetes Mellitus • Most often begins with an infection • Can also be seen in Type II Diabetes Mellitus if illness or stress exceeds the ability of the pancreas to secrete adequate insulin • Death occurs in 1 – 10% of cases even with appropriate treatment • Onset is sudden (less than 24 hours) • Diagnostic criteria includes hyperglycemia, hyperketonemia, and metabolic acidosis

30. DKA (cont’d) Pathophysiology -- • Body is unable to utilize carbohydrates • Not enough insulin to transport glucose into the cells • Body resorts to utilizing fats for energy • Results in ketones in the blood and urine • Leads to acidosis Etiology – • Inadequate medication/insulin • Infection • Change in diet, exercise • Other stressors

31. DKA (cont’d) Clinical manifestations -- • Rapid, weak pulse • Kussmaul’s respirations • “Fruity” breath • Nausea/vomiting, abdominal pain • Dehydration • Polyuria, polydipsia • Normal/low temperature in the presence of infection • Weight loss • Dry skin • Sunken eyes, soft eyeballs • Lethargy, coma

32. DKA (cont’d) Lab findings – • Serum glucose = >300mg/dL • Serum ketones = positive • Urine ketones = positive • Serum pH = <7.35 • Serum HCO3 = <15mEq/L • Serum potassium = ↑ with acidosis, ↓ with dehydration • BUN = >20mg/dL due to dehydration • Creatinine + >1.5mg/dL due to dehydration

33. DKA (cont’d) Emergency management – • Establish a patent airway • Administer oxygen and NaHCO3 if ↓ pH • Place IV with large bore catheter • Administer NS per IV • 1L/hour for first 2-3 hours to stabilize blood pressure and ensure adequate urine output • IV fluid changed to D5 ½ NS when serum glucose reaches 250mg/dL • Urine output will decrease as osmotic diuresis effect of hyperglycemia is reduced • Careful monitoring of potassium level

34. DKA (cont’d) Ongoing monitoring – • Monitor blood glucose • Assess for hypokalemia • Potassium will reenter the cell with insulin administration • Will need to decrease infusion rate when blood glucose is ≤300mg/dL • Anticipate order of D5W when blood glucose level is 250mg/dL • Reduces risk of hypoglycemia • Assess for signs and symptoms of hypoglycemia • Anxiety, behavior changes, confusion, headache, slurred speech • Blurred vision, hunger, cold sweats, tachycardia

35. Hyperglycemic-Hyperosmolar Nonketotic Syndrome (HHNS) • HHNS is a medical emergency with a high mortality rate • Hyperosmolar state caused by hyperglycemia • Blood glucose = 800mg/dL • Serum osmolarity = possibly >350mOsm/L • Exhibits no ketosis • May be seen in Type II Diabetes Mellitus • Often related to impaired thirst sensation or functional inability to replace fluids

36. HHNS (cont’d) • Rapid progression • Hours to days • Clinical manifestations – • Polyuria, polydipsia, dehydration, aphasia • Altered mental status (lethargy → coma) • Postural hypotension, tachycardia • Seizures, tremors, nystagmus, hyperreflexia • Treatment – • Management is similar to DKA except HHNS requires greater fluid replacement as patient can have a 9-12L fluid deficit • Administer regular insulin at 0.1U/kg/hour until glucose level drops to 250mg/dL

37. HHNS (cont’d) • Treatment (cont’d) – • Fluid resuscitation • Administer 1-2L NS for 1st hour • Follow with 1L/hour for the next several hours • Hyperglycemia will decrease with fluid resuscitation • May need to give low-dose insulin if patient is hyperkalemic, acidotic, or in renal failure • Support airway, breathing, circulation

38. Differences between Diabetic Ketoacidosis (DKA) and Hyperglycemic-Hyperosmolar Nonketotic Syndrome (HHNS) DKAHHNS Onset Sudden Gradual Serum Glucose >300 >800 Serum Ketones Yes No Serum pH <7.35 >7.4 Serum HCO3 <15 mEq/L >20 mEq/L Serum K Normal Normal ↑ with acidosis ↓ with dehydration Serum Osmolarity Variable >350 mOsm/L BUN ↑ ~ dehydration ↑ Creatinine ↑ ~ dehydration ↑ Urine Ketones Positive Negative

39. Gastrointestinal Disturbances • The stomach is acidic • pH = 1.0 – 3.5 • Fluid volume deficit possible • Prolonged vomiting • Gastric suction • Monitor for hypokalemia • Potassium is present in gastric juices • Monitor for hyponatremia due to prolonged loss of sodium • Suctioning • Nasogastric irrigation with plain water

40. Fluid Volume Deficit • Types of fluid volume deficit – • Isotonic fluid loss • Hypertonic dehydration • Third spacing Isotonic Fluid Loss • Fluid and solute are lost equally • Serum osmolarity remains normal • Intracellular water is not disturbed • Fluid loss is extracellular fluid • Can quickly lead to shock • Requires extracellular fluid replacement • Emphasis is on increasing vascular volume

41. Isotonic Fluid Loss (cont’d) • Causes – • Hemorrhage • Loss of fluid, electrolytes, proteins, and blood cells results in inadequate vascular volume • Gastrointestinal losses • Vomiting, NG suctioning, diarrhea, drainage from fistulas/tubes • Fever, environmental heat, diaphoresis • Profuse sweating causes water and sodium loss through the skin • Burns • Damages skin capillary membranes • Allows fluid, electrolytes, and proteins to escape into burned tissue area, leaving less vascular volume

42. Isotonic Fluid Loss (cont’d) • Causes (cont’d) – • Diuretics can cause excessive loss of fluid and electrolytes • Third spacing • Fluid moves from the vascular space into extracellular spaces • Treatment – • Expand extracellular volume with isotonic IV fluids • Increases circulating blood volume • Restores renal perfusion • Provide blood transfusion for hypovolemia caused by hemorrhage

43. Isotonic Fluid Loss (cont’d) • Treatment (cont’d) – • Administer 1–2L bolus of isotonic fluid for adults • Infuse in 30 minutes or less • Administer up to an additional 2–3L • Improves urine output, blood pressure, heart rate, and mental status • Infuse 20–30 mL/kg bolus of isotonic fluid for infants/young children to improve urine output, heart rate, respiratory rate, and mental status

44. Hypertonic Dehydration • More water is lost than solute • Creates a solute excess • Primarily sodium • Results in fluid volume deficit • Solute can also be gained in excess of water • Creates a similar imbalance • Most common with sodium or glucose • Serum osmolarity becomes elevated • Results in hypertonic extracellular fluid • Pulls fluids into the vessels from the cells by osmosis • Causes cells to shrink and become dehydrated

45. Hypertonic Dehydration (cont’d) Causes – • Inadequate fluid intake • Inability to respond to thirst • May occur due to age (infants or the elderly), immobility, nausea, anorexia, dysphagia, or being NPO without fluid replacement • Severe or prolonged isotonic fluid losses • Extracellular fluid becomes hypertonic and draws water from the cells • Compensatory mechanisms become exhausted • Conservation of water via the kidneys depleted • Results in cellular dehydration • May occur with nausea/vomiting, diarrhea • Loss of more water than solute

46. Hypertonic Dehydration (cont’d) Causes (cont’d) – • Watery diarrhea • Loss of more water than electrolytes • Diabetes insipidus • Leads to massive, uncontrolled diuresis of dilute urine • As much as 30L/day • Can quickly lead to shock and death • Usually caused by a brain injury • Damages/puts pressure on the hypothalamus or pituitary gland • Need to administer parenteral vasopressin • In a fluid volume deficit related to diabetes insipidus, urine will be pale, dilute, and high in volume

47. Hypertonic Dehydration (cont’d) Causes (cont’d) – • Increased solute intake • Excessive salt, sugar, or protein intake without a proportional intake of water • Increases plasma osmolarity • Water is pulled from the cells, leading to cellular dehydration • Results in osmotic diuresis, which makes cellular dehydration worse • Dangerous for patients with heart or kidney problems Conditions that lead to hypertonic dehydration – • Highly concentrated enteral or parenteral feedings

48. Hypertonic Dehydration (cont’d) Conditions that lead to hypertonic dehydration (cont’d) – • Improperly prepared infant formulas that are too concentrated • Hyperglycemia and/or diabetic ketoacidosis • Excessive glucose and ketones in the blood • Increased sodium ingestion • Ingestion of excessive amounts of seawater • Taking salt water tablets • Excessive use of osmotic diuretics

49. Hypertonic Dehydration (cont’d) Clinical manifestations – • Thirst • Early sign of dehydration • Unreliable in the elderly and the very young • Concentrated urine • Dark in color • High specific gravity (normal is 1.010 – 1.030) • Low urine volume • Normal output for adults is 30mL/hour • Dry mucus membranes • When assessing mucus membranes, remember that environmental conditions can also cause dry lips

50. Hypertonic Dehydration (cont’d) Clinical manifestations (cont’d) – • Dry skin • Decreased turgor • Decreased elasticity • Tenting • Tissues stick together from interstitial fluid loss • Unreliable in the elderly due to decreased elastin • Test on sternum, forehead, inner thigh, top of hip instead of arms and legs • Check infant skin over abdomen or inner thighs • Dry tongue with longitudinal furrows • Decreased tearing with dry conjunctiva • Sunken eyes