Section

• General

  
  

  • Announcements Forum
  • INTRODUCTION

    
    

    Welcome to AN3163 Fluids and Electrolyte Balance and Perioperative!

    This subject aims to provide a general introduction to the basic topics in Fluid and electrolyte and Perioperative.

    Fluid and electrolyte are a key concept to understand for maintaining homeostasis, and for successful treatment of many metabolic disorders. There are various regulating mechanisms for the equilibrium of electrolytes in organisms. Disorders of these mechanisms result in electrolyte imbalances that may be life-threatening clinical conditions. Understanding the basics of these complex concepts is vital to your success in caring for complex patients.

    The perioperative period begins when the patients is informed of the need of surgery, includes the surgical procedure and recovery, continues with discharge, and ends when the patient achieves his or her optimal level of postsurgical function. The perioperative nursing provides essential knowledge of pre-, intra-, and post-operative practices through the continuum of care for surgical patients. The nurse helps to plan, implement, and evaluate treatment of the surgical patient and may work closely with the patient, family members, and other health care professionals.

    In this course guide, I will share the course learning outcomes, the overview of the plan of the course and the assessments. I will also share the expectations of being a student in this course. It is our intent to make this learning experience both convenient and fun while achieving the intended outcomes.
• 

  Open allClose all

  
• 

  Instructions: Clicking on the section name will show / hide the section.

  

• Course Guide

  
  

  INTRODUCTION

  Welcome to AN3136 Perioperative and Fluid and Electrolyte. This subject is comprised of the foundation of fluids and electrolytes balances and imbalances, as well as, caring for clients undergoing surgery, as well as, caring for clients undergoing surgery.

  In the course guide, I will share the course learning outcomes, the overview of the plan of the course and the assessment. I will also share the expectations of being a student in this course. It is our intent to make this learning experience both convenient and fun while achieving the intended outcomes.

  COURSE LEARNING OUTCOME

  A course learning outcome (CLO) is the expectation of what you should be able to do by the end of the course. It provides a guide to both the educator as well as the student to focus on achieving the intended outcomes. For this course, we have three course learning outcomes (CLO) that can be categorized into two domains; cognitive(C) and affective(A). The CLOs are as follows:

  • CLO1 Construct a comprehensive, individualized care plan based on a given scenario of clients undergoing surgery using the nursing process. (C3, PLO2)
  • CLO2 Explain the concepts of fluid and electrolyte balance and acid base balance (C2, PLO1)
  • CLO3 Demonstrate the ability,to reflect upon nursing practice for awareness and improvement (A4, PLO9)

  OVERVIEW OF TEACHING AND LEARNING

  As an online course, we will use the Learning Management System (LMS) for all our communication, materials and assessments. We will have synchronous meeting via the LMS as well as Self Instructional Materials (SIM) to facilitate your learning and progress through the course. As an ODL learner, you are expected to be self directed. The SIM will provide you with a complete guide of the course materials and resources. Each topic will have topic learning outcomes followed by the lesson notes. Links to videos and other resources will be provided to support your learning process. You will also be given reading materials out of the SIM. At the end of each topic, there will be self check questions. Here you can test yourself. Review the notes and resources should you need to. We will also have scheduled online meetings. Here we will have discussions and tutorials. We will have a total of four (4) synchronous meetings over the semester.

  ASSESSEMENT

  The assessments are planned as coursework and well as a summative examination. The breakdown of the weightage is as follows:

  A. Continuous Assessment Weightage (%)
  Test I 10%
  Test II 10%
  Reflective Essay 20%

  B. Summative Assessment
  Final Exam 60%
  
  Total 100%

  YOUR RESPONSIBILITY AS AN ODL STUDENT

  The concept of ODL is to be flexible and facilitate learning even while working. As an ODL student, you are expected to be self directed. Utilise the SIM provided and make full use of the resources (recorded lectures, videos, readings) provided. Attend synchronous meetings to facilitate discussion, clarification and guidance. You are expected to attend at least 85% of synchronous meeting. Should you miss the meeting, do refer to the recordings that will be uploaded after the meeting.

  Academic Honesty
  
  Cheating, in any form, is a very serious offence which could lead to severe disciplinary action. Cheating includes:

  • using unauthorised materials in tests and examinations;
  • letting another person take tests or examinations on one’s behalf OR taking tests or examinations on another person’s behalf;
  • working jointly, copying or sharing another student’s work and presenting it as one’s own piece of work
  • inventing, copying or altering data, quotations or references;
  • plagiarising, i.e. taking or using another person’s work without attributing the source and thus, giving the impression that it is one’s own work.

  Any student caught and found guilty in the disciplinary hearing will be deemed to have FAILED in the subject and will be required to REPEAT the said subject. Any repeated offence may result in EXPULSION FROM THE UNIVERSITY

  CLOSING NOTE

  We are glad to have you with us 😃. Let's look forward to a fun, challenging and fruitful semester.
  Do contact me should you need any help. I will be gladly assist you.

  
  

  Ng Kim Lian
  klng@nilai.edu.my
  
• Topic 1 : Care of Client During Perioperative Period

  INTRODUCTION

  Sterilization and disinfection are the basic components of hospital infection control activities. Every day, a number of hospitals are performing various surgical procedures. The medical device or the surgical instrument that comes in contact with the sterile tissue or the mucus membrane of the patient during the various processes is associated with increased risk of introduction of pathogens into the patient’s body. Moreover, there is chance of transmission of infection from patient to patient; from patient or to health care personnel, and vice versa [e.g., hepatitis B virus (HBV)]; or from the environment to the patient (e.g., Pseudomonas aeruginosa, Acinetobacter spp.) through the improper sterilized or disinfected devices. A number of outbreaks and infections were reported in the hospital setup because of improperly sterilized devices. Many infections were reported throughout the world due to use of contaminated endoscopes. Hence, adequate decontamination techniques for medical and surgical devices are needed in all the health care facilities.

  LEARNING OUTCOME

  At the end of the lecture, the students will be able to:

  • Explain the Principles of sterilization and disinfection
  • Explain the Principles of surgical asepsis
  • Explain the Universal Precautions

  • LEARNING RESOURCES

  • What is Sterilization and Disinfection? Page

    Mark as done
  • Principles of Surgical Asepsis Page

    Mark as done
  • Principles of The Aseptic Technique Page

    Mark as done
  • Creating A Sterile Field Page

    Mark as done
  • Universal Precautions Page

    Mark as done
  • LEARNING RESOURCES - VIDEOS

  • Universal Precautions Training URL

    Mark as done
  • KNOWLEDGE CHECK ACTIVITIES

  • Topic 1 Discussion Forum

    View Make forum posts: 1

    Students, please answer the questions posted in this forum. 

  • Test Your Knowledge 1 (1 SLT) Quiz

    View

    Dear students, please complete this quiz to test your understanding of Topic 1. 

  • CONCLUSION

    The practice of aseptic technique requires an understanding of the principles involved, adherence to proper procedures, use of the right resources and a proper environment. While vigilance and supervision are essential, compliance can only be achieved through individual commitment and attention.

  • REFERENCES

    Sara, L., Justine, H. & Hayley, G. (2020). The Royal Marsden Manual of Clinical Nursing Procedures (10th ed). United States: John Wiley and Sons Ltd

    Sutherland-Fraser. S., Menna, D., Brigid, M. G. & Benjamin, L. (2020). Perioperative Nursing : An Introduction (3rd ed). Australia: Elsevier

    LeMone, P. & Burke, K.M. (2019). LeMone and Burke's Medical-Surgical Nursing : Clinical Reasoning in Patient Care. (7th ed.). USA: Pearson

    Baranoski, S. (2020). Wound Care Essentials :Practice Principles (5th ed). USA: Wolters Kluwer Health

    Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.).Philadelphia: Wolters Kluwer Health.

  
• Topic 2 : Care of Client During Preoperative Period

  INTRODUCTION

  Surgery is a medical specialty that focuses on the use of operative techniques to investigate and resolve certain medical conditions caused by disease or traumatic injury. Surgery can have many possible purposes, such as to improve bodily function, enhance physical appearance, or repair damaged or ruptured areas.

  LEARNING OUTCOME

  At the end of the lecture, the students will be able to:

  • Explain the three phases of the perioperative period correctly
  • Explain the classification of surgery
  • Explain surgical setting and its function
  • Explain improving Patient Safety in the Surgical Environment

  • LEARNING RESOURCES

  • Care of Client During Preoperative Period Book

    Mark as done
  • LEARNING RESOURCES - VIDEOS

  • Pre Operative Nursing Care URL

    Mark as done

    
    

  • KNOWLEDGE CHECK ACTIVITIES

  • Topic 2 Discussion Forum

    Mark as done

    Students, please answer the questions posted in this forum.

  • CONCLUSION

    Ensuring patient safety in the operating room begins before the patient enters the operative suite and includes attention to all applicable types of preventable medical errors (including, for example, medication errors), but surgical errors are unique to this environment. Steps to prevent wrong-site, wrong-person, wrong-procedure errors, or retained foreign objects have been recommended, starting with structured communication between the patient, the surgeon(s), and other members of the health care team. Prevention of surgical errors requires the attention of all personnel involved in the patient’s care.

  • REFERENCES

    Sara, L., Justine, H. & Hayley, G. (2020). The Royal Marsden Manual of Clinical Nursing Procedures (10th ed). United States: John Wiley and Sons Ltd

    Sutherland-Fraser. S., Menna, D., Brigid, M. G. & Benjamin, L. (2020). Perioperative Nursing : An Introduction (3rd ed). Australia: Elsevier

    LeMone, P. & Burke, K.M. (2019). LeMone and Burke's Medical-Surgical Nursing : Clinical Reasoning in Patient Care. (7th ed.). USA: Pearson

    Baranoski, S. (2020). Wound Care Essentials :Practice Principles (5th ed). USA: Wolters Kluwer Health

    Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.).Philadelphia: Wolters Kluwer Health.

  
• Topic 3 : Pre-operative Management and Nursing Care Using The Nursing Process

  INTRODUCTION

  Preoperative care: Care given before surgery when physical and psychological preparations are made for the operation, according to the individual needs of the patient. The preoperative period runs from the time the patient is admitted to the hospital or surgicenter to the time that the surgery begins.

  LEARNING OUTCOME

  At the end of the lecture, the students will be able to:

  • Explain the preoperative Nursing Assessment
  • Explain preoperative health teaching
  • Explain the importance and understanding of consent preoperative
  • Explain the Pre-anesthetic care to the patient
  • Explain the classification of Anaesthesia

  • LEARNING RESOURCES

  • Preoperative Management and Nursing Care Using The Nursing Process Book

    Mark as done
  • LEARNING RESOURCES - VIDEOS

  • General Anesthetics Overview | Anesthesiology URL

    Mark as done

    
    

  • KNOWLEDGE CHECK ACTIVITIES

  • Topic 3 Discussion Forum

    Mark as done

    Students, please answer the questions posted in this forum. 

  • Test Your Knowledge 1 Quiz

    Mark as done

    Dear students, please complete this quiz to test your understanding of Topic 3. 

  • REFERENCES

    Sara, L., Justine, H. & Hayley, G. (2020). The Royal Marsden Manual of Clinical Nursing Procedures (10th ed). United States: John Wiley and Sons Ltd

    Sutherland-Fraser. S., Menna, D., Brigid, M. G. & Benjamin, L. (2020). Perioperative Nursing : An Introduction (3rd ed). Australia: Elsevier

    LeMone, P. & Burke, K.M. (2019). LeMone and Burke's Medical-Surgical Nursing : Clinical Reasoning in Patient Care. (7th ed.). USA: Pearson

    Baranoski, S. (2020). Wound Care Essentials :Practice Principles (5th ed). USA: Wolters Kluwer Health

    Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.).Philadelphia: Wolters Kluwer Health.

  
• Topic 4 : Intra- Operative Management and Nursing Care Using The Nursing Process

  INTRODUCTION

  The intraoperative phase is the time period from when the patient is on the operating table to when the operation has finished and the wound is closed (if relevant). We consider any activity taking place after induction of anaesthesia to be in this phase because this starts in the operating theatre itself.

  LEARNING OUTCOME

  At the end of the lecture, the students will be able to:

  • Explain the physical environment of the operating room
  • Explain the surgical team

  • LEARNING RESOURCES

  • Intra- Operative Management and Nursing Care Using The Nursing Process Book

    Mark as done
  • KNOWLEDGE CHECK ACTIVITIES

  • Topic 4 Discussion Forum

    Mark as done

    Students, please answer the questions posted in this forum. 

  • CONCLUSION

    • Differentiate the purposes of the various areas of the perioperative/surgery department and the proper attire for each area.
    • Differentiate the roles and responsibilities of the interdisciplinary surgical team members.
    • Prioritize needs of patients undergoing surgery.
    • Analyse the role of the perioperative nurse in the management of the patient undergoing surgery.
    • Apply basic principles of aseptic technique used in the operating room.
    • Evaluate the importance of safety in the operating room relative to patients, equipment, and anesthesia.
  • REFERENCES

    Sara, L., Justine, H. & Hayley, G. (2020). The Royal Marsden Manual of Clinical Nursing Procedures (10th ed). United States: John Wiley and Sons Ltd

    Sutherland-Fraser. S., Menna, D., Brigid, M. G. & Benjamin, L. (2020). Perioperative Nursing : An Introduction (3rd ed). Australia: Elsevier

    LeMone, P. & Burke, K.M. (2019). LeMone and Burke's Medical-Surgical Nursing : Clinical Reasoning in Patient Care. (7th ed.). USA: Pearson

    Baranoski, S. (2020). Wound Care Essentials :Practice Principles (5th ed). USA: Wolters Kluwer Health

    Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.).Philadelphia: Wolters Kluwer Health.

  
• Topic 5 : Post-Operative Management and Nursing Care Using The Nursing Process [Part 1]

  INTRODUCTION

  Post-operative care monitors a patient's recovery by controlling pain, watching for infection, and assessing for postoperative complications that may arise.

  LEARNING OUTCOME

  At the end of the lecture, the students will be able to:

  • Explain the post-operative care
  • Prepare operation bed
  • Prepare anaesthetic tray

  • LEARNING RESOURCES

  • Post-Operative Management and Nursing Care Using The Nursing Process Part 1 Book

    Mark as done
  • LEARNING RESOURCES - VIDEOS

  • Postoperative Care URL

    Mark as done

    
    

  • KNOWLEDGE CHECK ACTIVITIES

  • Topic 5 Discussion Forum

    Mark as done

    Students, please answer the questions posted in this forum. 

  • Test Your Knowledge 1 Quiz

    Mark as done

    Dear students, please complete this quiz to test your understanding of Topic 5. 

  • REFERENCES

    Sara, L., Justine, H. & Hayley, G. (2020). The Royal Marsden Manual of Clinical Nursing Procedures (10th ed). United States: John Wiley and Sons Ltd

    Sutherland-Fraser. S., Menna, D., Brigid, M. G. & Benjamin, L. (2020). Perioperative Nursing : An Introduction (3rd ed). Australia: Elsevier

    LeMone, P. & Burke, K.M. (2019). LeMone and Burke's Medical-Surgical Nursing : Clinical Reasoning in Patient Care. (7th ed.). USA: Pearson

    Baranoski, S. (2020). Wound Care Essentials :Practice Principles (5th ed). USA: Wolters Kluwer Health

    Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.).Philadelphia: Wolters Kluwer Health.

  
• Topic 6 : Post-Operative Management and Nursing Care Using The Nursing Process [Part 2]

  INTRODUCTION

  Many people have complications after surgery; some transient, others serious, but all are important to patients. The likelihood of postoperative complications is influenced by the type of surgery, the patients pre-existing comorbid state and perioperative management. Postoperative complications can be general or specific to particular operations and can also be classed according to their time of onset: immediate, early and late.

  LEARNING OUTCOME

  At the end of the lecture, the students will be able to:

  • Explain the post-operative discomfort and complications
  • Explain postoperative health education and discharge plan

  It’s also important to learn how to prevent, recognize, and respond to possible complications. Depending on the type of surgery you have, there are many potential complications that can arise. For example, many surgeries put patients at risk of infection, bleeding at the surgical site, and blood clots caused by inactivity. Prolonged inactivity can also cause you to lose some of your muscle strength and develop respiratory complications.

  • LEARNING RESOURCES

  • Post-Operative Management and Nursing Care Using The Nursing Process Part 2 Book

    Mark as done
  • LEARNING RESOURCES - VIDEOS

  • Surgical Emergencies - Post Operative Complications URL

    Mark as done

    
    

  • KNOWLEDGE CHECK ACTIVITIES

  • Topic 6 Discussion Forum

    Mark as done

    Students, please answer the questions posted in this forum. 

  • Test Your Knowledge 1 Quiz

    Mark as done

    Dear students, please complete this quiz to test your understanding of Topic 6. 

  • REFERENCES

    Sara, L., Justine, H. & Hayley, G. (2020). The Royal Marsden Manual of Clinical Nursing Procedures (10th ed). United States: John Wiley and Sons Ltd

    Sutherland-Fraser. S., Menna, D., Brigid, M. G. & Benjamin, L. (2020). Perioperative Nursing : An Introduction (3rd ed). Australia: Elsevier

    LeMone, P. & Burke, K.M. (2019). LeMone and Burke's Medical-Surgical Nursing : Clinical Reasoning in Patient Care. (7th ed.). USA: Pearson

    Baranoski, S. (2020). Wound Care Essentials :Practice Principles (5th ed). USA: Wolters Kluwer Health

    Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.).Philadelphia: Wolters Kluwer Health.

  
• Topic 7 : Perioperative Procedures

  INTRODUCTION

  The process of scrubbing, gowning, and gloving is one that all members of the surgical team must complete before each operation.

  In the surgical scrub, the hands and forearms are decontaminated. A sterile surgical gown and pair of gloves are subsequently donned, creating an aseptic environment.

  ‘Scrubbing in’ dramatically reduces the risk of infection and significantly improves patient outcomes. As such, it is a skill that should be taken seriously and always performed to the highest standard.

  Sterile procedures are required before and during specific patient care activities to maintain an area free from microorganisms and to prevent infection. Performing a surgical hand scrub, applying sterile gloves, and preparing a sterile field are ways to prevent and minimize infection during surgeries or invasive procedure.

  LEARNING OUTCOME

  At the end of the lecture, the students will be able to:

  • Demonstrate the ability to reflect upon nursing practice for awareness and improvement.
  • Identify the importance of each procedures that would lead to SSI Surgical Site infection.
  • The purpose of carrying out surgical hand washing donning sterile gown and glove.

  
  

  • LEARNING RESOURCES

    THE IMPORTANCE OF DONNING STERILE GOWN AND GLOVES

    The surgical team should wear a sterile gown and gloves to reduce the risk of SSIs. Aseptic practices, including scrubbing, gloving, barrier clothing, drapes, and instrument sterilization, are pivotal to protecting the integrity of the sterile field.

    A surgical gown is a personal protective garment intended to be worn by health care personnel during surgical procedures to protect both the patient and health care personnel from the transfer of microorganisms, body fluids, and particulate matter.

    
    

    THE IMPORTANCE OF EACH PROCEDURES THAT WOULD LEAD TO SURGICAL SITE INFECTION (SSI)

    One of the major concerns of the perioperative team is surgical site infections (SSIs). An infection that develops due to the transfer of microorganisms to the patient's wound during surgery is called SSI. It threatens the lives of millions of people each year due to antibiotic-resistant infections. It is the most common type of nosocomial infection in patients who have undergone surgical procedures. Approximately seven percent of the patients in developed nations and more than 25% of the patients in developing countries are affected by healthcare-associated infections (HCAIs).

    SSIs result in delayed wound healing, increased hospital stays, increased use of antibiotics, unnecessary pain, and in extreme cases, even death of the patient. Hence, their prevention is a crucial aim of health services. According to estimates, 26-54% of such infections can be avoided. Proper aseptic techniques, including hand hygiene, can prevent these infections. The surgical team should wear a sterile gown and gloves to reduce the risk of SSIs.

    Aseptic practices, including scrubbing, gloving, barrier clothing, drapes, and instrument sterilization, are pivotal to protecting the integrity of the sterile field. However, because of the fast-paced nature of the operating room (OR), the short time available for training, and the scarcity of experienced medical personnel, these abilities are challenging for medical students to learn. Hand preparation for surgery includes initial hand washing, procedural steps of rubbing, drying off hands, wearing an operating gown, and wearing sterile surgical gloves.

    In 2008, an initiative of 'Clean Care is Safer Care' was launched by the World Health Organization (WHO) to improve hand hygiene (HH) compliance among healthcare workers (HCWs).

    Gloves, gowns, and masks have a role in preventing infections but are often misused, increasing service costs unnecessarily. This surgical audit aims to assess glove-donning practices in the elective surgical operation theatre There is a scarcity of such clinical audits on standard donning sterile surgical gloves practices. To our best knowledge, this is the first in-field prospective audit on this topic from, using the WHO standard guidelines and involving education and assessment of the participants.

    Clinical audit was performed and indicating that more audits are required to improve patient safety. On the other hand, significant progress was made through the training sessions. Clinical audits that are conducted periodically are of the utmost significance in bringing about a good change in clinical practice.

    More audits should be done on a regular basis to improve adherence to standard guidelines. This can lead to a significant improvement in the reduction of health hazards, which still in turn, can help a country's economy by reducing prolonged hospital stays and minimizing the iatrogenic disease burden. Such clinical audits provide the framework to improve patient care collaboratively and systematically and educate healthcare professionals to become better caregivers and overcome their shortcomings. This also highlights the importance of intervention for amelioration/improvement.

    Mark as done
  • LEARNING RESOURCES - VIDEOS

  • Hand Scrubing URL

    Mark as done

    
    

  • Opening Sterile Pack URL

    Mark as done

    
    

  • KNOWLEDGE CHECK ACTIVITIES

  • Topic 7 Discussion Forum

    Mark as done

    Students, please answer the questions posted in this forum. 

    
    

  • CONCLUSION

    Staff who do not perform the procedures properly should have a live teaching perhaps a video and reaudit. To reduce mortality and morbidity cause by HAIS and SSI ,the issue need to be address quickly perhaps mentoring and checklist of new staff and trainees to operation Theatre.

  • REFERENCES

    Sara, L., Justine, H. & Hayley, G. (2020). The Royal Marsden Manual of Clinical Nursing Procedures (10th ed). United States: John Wiley and Sons Ltd

    Sutherland-Fraser. S., Menna, D., Brigid, M. G. & Benjamin, L. (2020). Perioperative Nursing : An Introduction (3rd ed). Australia: Elsevier

    LeMone, P. & Burke, K.M. (2019). LeMone and Burke's Medical-Surgical Nursing : Clinical Reasoning in Patient Care. (7th ed.). USA: Pearson

    Baranoski, S. (2020). Wound Care Essentials :Practice Principles (5th ed). USA: Wolters Kluwer Health

    Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.).Philadelphia: Wolters Kluwer Health.

  
• Topic 8 : Care of Client With Fluids And Electrolytes Imbalance

  INTRODUCTION

  Drinking water does more than just quench your thirst. It's essential to keeping your body functioning properly and feeling healthy.

  Nearly all of your body's major systems depend on water to function and survive. With water making up about 60% of your body weight, it's no surprise what staying hydrated can do for you.

  LEARNING OUTCOME

  At the end of the lecture, the students will be able to:

  • Explain the water content of the body and its importance
  • Explain Homeostasis and its functions
  • Explain electrolytes and its function

  • LEARNING RESOURCES

  • What is the importance of water content of the body? Book

    Mark as done
  • LEARNING RESOURCES - VIDEOS

  • Osmosis. Distribution of fluids within the body URL

    Mark as done

    
    

  • Overview of Fluid and Electrolyte Physiology (Fluid Compartment) URL

    Mark as done

    
    

  • KNOWLEDGE CHECK ACTIVITIES

  • Topic 8 Discussion Forum

    Mark as done

    Students, please answer the questions posted in this forum. 

    
    

  • Test Your Knowledge 1 Quiz

    Mark as done

    Dear students, please complete this quiz to test your understanding of Topic 8.

    
    

  • REFERENCES

    Sara, L., Justine, H. & Hayley, G. (2020). The Royal Marsden Manual of Clinical Nursing Procedures (10th ed). United States: John Wiley and Sons Ltd

    Sutherland-Fraser. S., Menna, D., Brigid, M. G. & Benjamin, L. (2020). Perioperative Nursing : An Introduction (3rd ed). Australia: Elsevier

    LeMone, P. & Burke, K.M. (2019). LeMone and Burke's Medical-Surgical Nursing : Clinical Reasoning in Patient Care. (7th ed.). USA: Pearson

    Baranoski, S. (2020). Wound Care Essentials :Practice Principles (5th ed). USA: Wolters Kluwer Health

    Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.).Philadelphia: Wolters Kluwer Health.

  
• Topic 9 : Care of Client With Fluids And Electrolytes Imbalance (Process of Movement Across The Membranes)

  INTRODUCTION

  Fluids and Electrolytes constantly shift from intracellular compartment to the extracellular compartments and vice versa so that the following vital body processes can take place:

  • TISSUE OXYGENATION (from the capillaries to the cells)
  • ACID BASE BALANCE (pH BALANCE)
  • URINE FORMATION (in the nephrons in the kidney)

  Each body compartment has a membrane to contain the components within it:

  • Cell, blood vessel, interstitial space, body cavities

  LEARNING OUTCOME

  At the end of the lecture, the students will be able to:

  • Explain the mechanisms controlling fluid and electrolytes movement capillaries extracellular and intracellular

  • LEARNING RESOURCES

  • Care of Client With Fluids and Electrolytes Imbalance (Process of Movement Across The Membranes) Book

    Mark as done
  • KNOWLEDGE CHECK ACTIVITIES

  • Topic 9 Discussion Forum

    Mark as done

    Students, please answer the questions posted in this forum. 

    
    

  • REFERENCES

    Sara, L., Justine, H. & Hayley, G. (2020). The Royal Marsden Manual of Clinical Nursing Procedures (10th ed). United States: John Wiley and Sons Ltd

    Sutherland-Fraser. S., Menna, D., Brigid, M. G. & Benjamin, L. (2020). Perioperative Nursing : An Introduction (3rd ed). Australia: Elsevier

    LeMone, P. & Burke, K.M. (2019). LeMone and Burke's Medical-Surgical Nursing : Clinical Reasoning in Patient Care. (7th ed.). USA: Pearson

    Baranoski, S. (2020). Wound Care Essentials :Practice Principles (5th ed). USA: Wolters Kluwer Health

    Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.).Philadelphia: Wolters Kluwer Health.

  
• Topic 10 : Fluid and Electrolytes Imbalances Collaboration Care and Nursing Management Using The Nursing Process [Part 1]

  INTRODUCTION

  Excess fluid in the bloodstream can be caused by water retention, drinking excessive amounts of water, decreased ability of the kidneys to produce urine, or an elevated blood pressure and bounding pulses are often seen with fluid volume excess.

  Fluid volume deficit also known as dehydration can be a common occurrence and nursing diagnosis for many patients. Dehydration is when there is a loss of too much fluid from the body. This leads to a lack of water in the body's cells and blood vessels Decreased blood pressure with an elevated heart rate and a weak or thready pulse are hallmark signs of fluid volume deficit.

  LEARNING OUTCOME

  At the end of the lecture, the students will be able to:

  • Explain fluid excess/deficit causes, symptoms, treatment
  • Explain sodium, potassium, calcium, phosphate, magnesium imbalances

  What causes excessive fluid in the body?

  Fluid overload is also called hypervolemia. It's when you have too much fluid in your body. It can be caused by several different conditions including heart failure, kidney failure, cirrhosis, or pregnant

   

  Water retention, called “edema”, refers to excess fluid that is improperly stored in the muscles and other organs of the body. The main causes of water retention are a sodium-heavy diet and lifestyles in which sitting and standing for many hours. The main symptom of water retention is the swelling of extremities and puffiness in the abdomen and face.   Treatment for water retention is lifestyle changes, like increasing movement and altering diet.

  Edema is caused by nutrient deficiencies and imbalances, with vitamin A, vitamin C, vitamin B-6, magnesium, and zinc being common vitamins and minerals that have an effect on symptoms. , edema is affected by behavioural habits; the way a person physically moves and exercises and how they massage their muscles has a significant impact on the presence or severity of the disease

  The causes of water retention include numerous diseases plus some lifestyle issues.

  ·         Too much salt in my diet. Excess salt in the body disrupts the body’s water balance and can result in fluid storage in the muscles.

  ·         Certain medications. Hormonal medications, diabetic medications, and many other types of prescription medications may affect fluid retention and cause edema.

  ·         Kidney disease. Improper functioning of the liver can cause fluid build-up, including from diseases like glomerulonephritis and nephrotic syndrome.

  ·         Lack of movement. Sitting too long can make it harder for the blood to circulate from the legs back up to the heart.

  ·    Cancer. Malignant tumours on the muscles and lymph nodes can cause edema.

  ·    Heart failure. If the heart is not able to pump blood as normal it will try to make up for the poor circulation by increasing the amount of blood it is circulating through the body. This causes the liver, body cavities, and legs among other locations to swell.

  Chronic lung disease. When fluid builds up in the lungs·   , it is called pulmonary edema. There is a circular effect from emphysema (damaged air sacs in the lungs) causing shortness of breath that causes the heart to pump harder, which then creates pressure from blood vessels that pushes fluid into the lungs and makes breathing even more difficult.

     Liver disease. Liver disease such as cirrhosis makes it more difficult for the organ to function, slowing blood flow. This causes increased pressure in the veins which can lead to fluid build-up in the legs.   Malignant lymphoedema. If cancer cells cause blockages in the lymphatic system, lymph fluid can back up in the body.

     Hormonal changes. Hormones are responsible for maintaining balance in the body, and so if there are disruptions to one’s hormones or a condition in the thyroid (the gland that produces many hormones), hydration levels may be affected and water retention is more likely to occur.

     Thyroid disease. Severe cases of hypothyroidism are called myxedema and can have numerous serious symptoms including major fluid retention and swelling, particularly in the legs and face.   Premenstrual syndrome (PMS). Hormonal changes surrounding PMS impact how fluid is stored in the body and can cause swelling.

  ·    Arthritis. The affected joints from arthritis will often swell with water, which often makes moving the affected joints even more difficult and painful.

    Allergic reaction. An allergic reaction is an underlying reason behind some people’s edema. A major allergic reaction often causes immediate inflammation and bloating, but smaller allergies may cause milder but still noticeable swelling and edema.

     Autoimmune diseases such as lupus. Lupus prevents the kidneys from functioning properly, leading to fluid build-up that can cause water retention and swelling.

  ·  Substantial changes in air pressure. Air pressure affects how the body stores water, so plane rides may be one reason for water retention. Symptoms of Water Retention

  
  

  Generalized edema -Swelling. Particularly in the fingers, , ankles, feet, toes and lower legs that is due to fluid retention.

  · Bloating. Particularly in the stomach and abdomen.

  · Puffiness. The cheeks, eyes, or entire face may be puffy in appearance and to the touch because of water retention.

  · Stiffness and muscle pain. Water retention often makes the affected body parts feel stiffer, and it may become painful to move the affected areas.

  · Fatigue and lethargy. The excess water from edema may cause significant fatigue and lethargy, as the muscles become heavier and more sensitive.

    Crackles in the lungs upon auscultation Dyspnea• Orthopnea Cough

  ·   Weight gain, , Headache

      Treatments for Water Retention

  1.    Controlling salt consumption

  2.    Adding magnesium to the daily diet

  3.   Adding potassium to the daily diet

  4   Consuming b-6 supplements

  5.   Consuming more protein

  6   Use compression socks

  7.   Consume dandelion

  8.  Don't consume refined carbs

  9. Implement self-treatment for fluid retention

  10.   Seek medical care from doctor

  Three of the most efficient methods for treating water retention are reducing salt intake, increasing magnesium in your diet, and using compression socks.

  Controlling salt comsumption

  Controlling salt consumption is one of the best treatments for water retention, as fluid retention is typically due to high salt concentrations in the body. symptom. Try to avoid foods with high sodium and salt content. This includes salted meats, processed cheeses, salty snacks, or dishes that heavily use soy sauce. Cutting back on these foods helps to reduce salt levels and restore the proper ratio of water to salt in the body.

  2. Consuming Vitamin B-6 Supplements

  Consuming vitamin B-6 supplements helps to treat water retention by providing the body with the proper tools to help build red blood cells.

  3 Don't Consume Refined Carbs

  If possible, do not consume refined carbs (foods like pasta, bread, and other grains) in abundance if you want to treat water retention.  Many nutritionists have identified these foods as common culprits for stomach and abdominal bloating. Additionally, these foods may have high sodium or salt contents, making them not ideal in the treatment of water retention.

  4. Adding Magnesium to the Daily Diet

  Adding magnesium to your daily diet can effectively treat water retention, particularly in those whose fluid retention symptoms are caused by premenstrual syndrome or other estrogen-specific hormonal change. The Journal of Women’s Health found that when women were given 200 mg of magnesium supplement pills, most of their fluid retention symptoms – bloating in the abdomen, swelling of the breasts and extremities, and weight gain – were significantly decreased within two months. People should receive daily in their diet is between 310-400 mg. Magnesium-rich foods, such as those illustrated below, include cereals, yogurt, rice, black beans, and peanut butter. Chia seed

  
  

  
  

  5,Adding potassium to daily diet

  Adding potassium to your daily diet is another easy way to treat water retention at home, as potassium helps process sodium (salt) out of the body. Eating foods high in potassium – such as bananas, sweet potato, spinach, avocados, and mushrooms (illustrated below) – reduces the bloating from fluid retention and “helps relax blood vessel walls, which helps lower blood pressure,” .

  
  

  The American Heart Association notes that “most women should get 2,600 milligrams of potassium a day and men 3,400 milligrams a day, but… on average, men eat about 3,000 mg/day, and women eat about 2,300 mg/day” (2018).

  6 Comsuming  more protein

  Consuming more proteins – such as meat, beans, leafy green vegetables, etc. – helps with treating water retention. In patients with liver disease, protein deficiency is common and may contribute to symptoms of edema, particularly in the lower extremities. According to the Gastroenterological Society of Australia, patients with chronic liver disease can manage their symptoms (including fluid retention symptoms) by incorporating low-salt, high-protein foods into their daily diet, such as the examples below.

  
  

  
  

  
  

   7Use compression socks

  Compression socks are a helpful tool in treating water retention, as they relieve the symptom of swelling in the legs and feet by preventing blood from pooling there so it returns more quickly to the heart for circulation. Compression socks are one of the most common treatments for edema in the feet and ankles .. They are normally worn all day but taken off to sleep at night. They can have a rapid positive effect to reduce discomfort as soon as worn, though they are not a long-term cure.

  8 Consuming dandelion extract (known as “lion’s tooth”) may be helpful in treating fluid retention, as it is thought to be a natural diuretic with high levels of potassium. Those two aspects make it ideal for reducing salt levels in the body and flushing excess fluid through urination.

  9 Implement self-treatment for fluid retention

   Some additional at-home remedies include cardio exercises, massages, and soaking in an Epsom salt bath for 15-20 minutes. These additional remedies relieve some of the discomfort associated with water retention by improving circulation and easing muscle pain.

  Parsley aids in increased urine production, which is helpful with fluid retention. It is made     into tea and consumed daily. Calyces (from hibiscus plants). is said to reduce hypertension and treat mild edema. Green or black tea. Because of the caffeine content, both green and black tea may serve as diuretics.

  Drugs for Water Retention Treatment?

  The drugs for water treatment are usually diuretics, a type of medicine that increases urination. Diuretics are classified into three categories.

  1.   Thiazide. Including chlorthalidone and hydrochlorothiazide. These lower blood pressure as they work as a diuretic.

  2.   Loop. Including torsemide and furosemide. These are used for patients with chronic heart failure.

  3.   Potassium sparing. Including amiloride and triamterene. These diuretics deplete less of the body’s natural potassium than other diuretics do.

  
  

  1.   Congestive heart failure. Water retention can occur when a weakened heart is not pumping blood efficiently through the body.   Excess blood may back up in the legs, ankles, and feet, leading to edema.

  2.    Pregnancy. The additional weight in the abdomen puts pressure on the bladder and the legs, which may result in some fluid retention in the lower limbs, ankles, and feet.

  3.    Allergic reactions. The swelling of the face and limbs is a common side effect of allergic reactions. difficulty breathing, tightness in the chest, itchiness, hives, and red eyes are some other typical symptoms that occur.

  4.    Recovery from surgery. The stress of surgery and its recovery, and the more limited movement that can often occur post-surgery, may temporarily cause edema.

  5.   New medications. Sometimes a medication’s side effects include edema. If a new medicine is causing edema, consult with a doctor to see if the dosage is adjusted, or if an alternative medication is provided instead.

  6.   Poor diet. A diet that is inconsistent and/or unhealthy puts an individual at risk of experiencing fluid retention.

  7.    Venous insufficiency. A disease that “makes it hard for the veins to push blood back up to the heart,” and is often caused by chronic sitting/standing for long periods of time,

  Deficient Fluid Volume (also known as Fluid Volume Deficit (FVD), hypovolemia) is a state or condition where the fluid output exceeds the fluid intake. It occurs when the body loses both water and electrolytes from the ECF in similar proportions. Common sources of fluid loss are the gastrointestinal tract, polyuria, and increased perspiration. Risk factors for deficient fluid volume are as follows: vomiting, diarrhea, GI suctioning, sweating, decreased intake, nausea, inability to gain access to fluids, adrenal insufficiency, osmotic diuresis, haemorrhage, coma, third-space fluid shifts, burns, ascites, and liver dysfunction. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center, or home setting.

  Appropriate management is vital to prevent potentially life-threatening hypovolemic shock. Older patients are more likely to develop fluid imbalances. The management goals are to treat the underlying disorder and return the extracellular fluid compartment to normal, restore fluid volume, and correct any electrolyte imbalances.

  Aetiology for fluid volume deficit:

  • Abnormal losses through the skin, GI tract, or kidneys.
  • Decrease in intake of fluid (e.g., inability to intake fluid due to oral trauma)
  • Bleeding
  • Movement of fluid into third space.
  • Diarrhea
  • Diuresis
  • Abnormal drainage
  • Inadequate fluid intake
  • Increased metabolic rate (e.g., fever, infection)

  Signs and symptoms

  The following are the common signs and symptoms presented for dehydrated patients presenting fluid volume deficit that can help guide your nursing assessment:

  • Alterations in mental state
  • Patient complaints of weakness and thirst that may or may not be accompanied by tachycardia or weak pulse
  • Weight loss (depending on the severity of fluid volume deficit)
  • Concentrated urine, decreased urine output
  • Dry mucous membranes, sunken eyeballs
  • Weak pulse, tachycardia

  ·      Decreased skin turgor, Decreased weight

  • Decreased blood pressure, haemoconcentration
  • Postural hypotension, Dizziness, syncope

  Goals and outcomes for fluid volume deficit:

  • Patient is normovolemic as evidenced by systolic BP greater than or equal to 90 mm HG (or patient’s baseline), absence of orthostasis, HR 60 to 100 beats/min, urine output greater than 30 mL/hr and normal skin turgor.
  • Patient demonstrates lifestyle changes to avoid progression of dehydration.
  • Patient verbalizes awareness of causative factors and behaviors essential to correct fluid deficit.
  • Patient explains measures that can be taken to treat or prevent fluid volume loss.
  • Patient describes symptoms that indicate the need to consult with health care provider.

  Nursing assessment and rationales for fluid volume deficit

  1. Monitor and document vital signs, especially BP and HR.
  A decrease in circulating blood volume can cause hypotension and tachycardia. Alteration in HR is a compensatory mechanism to maintain cardiac output. Usually, the pulse is weak and irregular if electrolyte imbalance also occurs. Hypotension is evident in hypovolemia.

  2. Assess skin turgor and oral mucous membranes for signs of dehydration.
  Signs of dehydration are also detected through the skin. The skin of elderly patients losses elasticity.

  3. Monitor BP for orthostatic changes (changes seen when changing from supine to standing position). Monitor HR for orthostatic changes.
  A common manifestation of fluid loss is postural hypotension. It is manifested by a 20-mm Hg drop in systolic BP and a 10 mm Hg drop in diastolic BP. The incidence increases with age.

  4. Assess alteration in mentation/sensorium (confusion, agitation, slowed responses).
  Alteration in mentation/sensorium may be caused by abnormally high or low glucose, electrolyte abnormalities, acidosis, decreased cerebral perfusion, or developing hypoxia. Impaired consciousness can predispose a patient to aspiration regardless of the cause.

  5. Assess color and amount of urine. Report urine output less than 30 ml/hr for two (2) consecutive hours.
  Normal urine output is considered normal, not less than 30ml/hour. Concentrated urine denotes fluid deficit.

  6. Monitor and document temperature.
  Febrile states decrease body fluids by perspiration and increased respiration. This is known as insensible water loss.

  7. Monitor fluid status in relation to dietary intake.
  Most fluid comes into the body through drinking, water in food, and water formed by the oxidation of foods. Verifying if the patient is on a fluid restraint is necessary.

  8. Note the presence of nausea, vomiting, and fever.
  These factors influence intake, fluid needs, and route of replacement.

  9. Auscultate and document heart sounds; note rate, rhythm, or other abnormal findings.
  Cardiac alterations like dysrhythmias may reflect hypovolemia or electrolyte imbalance, commonly hypocalcemia. MI, pericarditis, and pericardial effusion with/ without tamponade are common cardiovascular complications.

  10. Monitor serum electrolytes and urine osmolality, and report abnormal values.
  Elevated blood urea nitrogen suggests fluid deficit. Urine-specific gravity is likewise increased.

  11. Ascertain whether the patient has any related heart problem before initiating parenteral therapy.
  Cardiac and older patients are often susceptible to fluid volume deficit and dehydration due to minor changes in fluid volume. They also are susceptible to the development of pulmonary edema.

  12. Weigh daily with the same scale, and preferably at the same time of day.
  Weight is the best assessment data for possible fluid volume imbalance. An increase in 2 lbs a week is considered normal.

  13. Identify the possible cause of the fluid disturbance or imbalance.
  Establishing a database of history aids accurate and individualized care for each patient.

  14. Monitor active fluid loss from wound drainage, tubes, diarrhea, bleeding, and vomiting; maintain accurate input and output record.
  Fluid loss from wound drainage, diarrhea, bleeding, and vomiting cause decreased fluid volume and can lead to dehydration.

  15. During treatment, monitor closely for signs of circulatory overload (headache, flushed skin, tachycardia, venous distention, elevated central venous pressure [CVP], shortness of breath, increased BP, tachypnea, cough).
  Close monitoring for responses during therapy reduces complications associated with fluid replacement.

  16. Monitor and document hemodynamic status, including CVP, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) if available in the hospital setting.
  These direct measurements serve as an optimal guide for therapy.

  17. Monitor for the existence of factors causing deficient fluid volume (e.g., gastrointestinal losses, difficulty maintaining oral intake, fever, uncontrolled type II diabetes mellitus, diuretic therapy).
  Early detection of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume. The gastrointestinal system is a common site of abnormal fluid loss.

  Nursing interventions for fluid volume deficit

  The following are the therapeutic nursing interventions for fluid volume deficit:

  1. Urge the patient to drink the prescribed amount of fluid.
  Oral fluid replacement is indicated for mild fluid deficit and is a cost-effective method for replacement treatment. Older patients have a decreased sense of thirst and may need ongoing reminders to drink. Being creative in selecting fluid sources (e.g., flavoured gelatine, frozen juice bars, sports drink) can facilitate fluid replacement. Oral hydrating solutions (e.g., Rehydrate) can be considered as needed.

  2. Aid the patient if they cannot eat without assistance, and encourage the family or SO to assist with feedings as necessary.
  Dehydrated patients may be weak and unable to meet prescribed intake independently.

  3. If the patient can tolerate oral fluids, give what oral fluids the patient prefers. Provide fluid and straw at bedside within easy reach. Provide fresh water and a straw.
  Most elderly patients may have a reduced sense of thirst and may require continuing reminders to drink.

  4. Emphasize the importance of oral hygiene.
  A fluid deficit can cause a dry, sticky mouth. Attention to mouth care promotes interest in drinking and reduces the discomfort of dry mucous membranes.

  5. Provide a comfortable environment by covering the patient with light sheets.
  Drop situations where patients can experience overheating to prevent further fluid loss.

  6. Plan daily activities.
  Planning conserves the patient’s energy.

  Interventions for severe hypovolemia:

  7. Insert an IV catheter to have IV access.
  Parenteral fluid replacement is indicated to prevent or treat hypovolemic complications.

  8. Administer parenteral fluids as prescribed. Consider the need for an IV fluid challenge with an immediate infusion of fluids for patients with abnormal vital signs.
  Fluids are necessary to maintain hydration status. Determination of the type and amount of fluid to be replaced and infusion rates will vary depending on clinical status.

  9. Administer blood products as prescribed.
  Blood transfusions may be required to correct fluid loss from active gastrointestinal bleeding.

  10. Maintain IV flow rate. Stop or delay the infusion if signs of fluid overload transpire, refer to physician respectively.
  Most susceptible to fluid overload are elderly patients and require immediate attention.

  11. Assist the physician with inserting the central venous line and arterial line, as indicated.
  A central venous line allows fluids to be infused centrally and for monitoring of CVP and fluid status. An arterial line allows for the continuous monitoring of BP.

  12. Provide measures to prevent excessive electrolyte loss (e.g., resting the GI tract, administering antipyretics as ordered by the physician).
  Fluid losses from diarrhea should be concomitantly treated with antidiarrheal medications, as prescribed. Antipyretics can decrease fever and fluid losses from diaphoresis.

  13. Begin to advance the diet in volume and composition once ongoing fluid losses have stopped.
  The addition of fluid-rich foods can enhance continued interest in eating.

  14. Encourage to drink bountiful amounts of fluid as tolerated or based on individual needs.
  A patient may have restricted oral intake in an attempt to control urinary symptoms, reducing homeostatic reserves and increasing the risk of dehydration or hypovolemia.

  15. Enumerate interventions to prevent or minimize future episodes of dehydration.
  A patient needs to understand the value of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits.

  16. Educate patient about possible causes and effects of fluid loss or decreased fluid intake.
  Enough knowledge aids the patient in taking part in their plan of care.

  17. Emphasize the relevance of maintaining proper nutrition and hydration.
  Increasing the patient’s knowledge level will assist in preventing and managing the problem.

  18. Teach family members how to monitor output in the home. Instruct them to monitor both intake and output.
  An accurate measure of fluid intake and output is an important indicator of a patient’s fluid status.

  19. Refer patient to home health nurse or private nurse to assist patient, as appropriate.
  Continuity of care is facilitated through the use of community resources.

  20. Identify an emergency plan, including when to ask for help.
  Some complications of deficient fluid volume cannot be reversed in the home and are life-threatening. Patients progressing toward hypovolemic shock will need emergency care.

  Basic physiology of electrolytes and their abnormalities, and the consequences of electrolyte imbalance.  

  Electrolytes are essential for basic life functioning, such as maintaining electrical neutrality in cells, generating and conducting action potentials in the nerves and muscles. Sodium, potassium, and chloride are the significant electrolytes along with magnesium, calcium, phosphate, and bicarbonates. Electrolytes come from our food and fluids. 

  These electrolytes can have an imbalance, leading to either high or low levels. High or low levels of electrolytes disrupt normal bodily functions and can lead to even life-threatening complications. 

  Sodium

  Sodium, which is an osmotically active cation, is one of the most important electrolytes in the extracellular fluid. It is responsible for maintaining the extracellular fluid volume, and also for regulation of the membrane potential of cells. Sodium is exchanged along with potassium across cell membranes as part of active transport. 

  Sodium regulation occurs in the kidneys. The proximal tubule is where the majority of sodium reabsorption takes place. In the distal convoluted tubule, sodium undergoes reabsorption.  Sodium transport takes place via sodium-chloride symporters, which are by the action of the hormone aldosterone.

  Among the electrolyte disorders, hyponatremia is the most frequent. Diagnosis is when the serum sodium level is less than 135 mmol/L. Hyponatremia has neurological Correction of body water osmolality restoration of cell volume by:

   provide high – sodium foods, below 125 mEq/L sodium and give 0.9 NaCl, or LR

  manifestations. Patients may present with headaches, confusion, nausea, delirium. 

  Hypernatremia presents when the serum sodium levels are greater than145 mmol/L. Symptoms of hypernatremia include tachypnea, sleeping difficulty, and feeling restless. Rapid sodium corrections can have serious consequences like cerebral edema and osmotic demyelination syndrome. 

  Hyponatremia Hypernatremia

  Potassium

  Potassium is mainly an intracellular ion. The sodium-potassium adenosine triphosphatase pump has the primary responsibility for regulating the homeostasis between sodium and potassium, which pumps out sodium in exchange for potassium, which moves into the cells. In the kidneys, the filtration of potassium takes place at the glomerulus. The reabsorption of potassium takes place at the proximal convoluted tubule and thick ascending loop of Henle. Potassium secretion occurs at the distal convoluted tubule. Aldosterone increases potassium secretion. Potassium channels and potassium-chloride cotransporters at the apical membrane also secrete potassium

  Potassium disorders are related to cardiac arrhythmias.

   Hypokalaemia occurs when serum potassium levels under 3.6 mmol/L—weakness, fatigue, and muscle twitching present in hypokalaemia

  Common causes: - Inadequate K+ intake, K+ loss exceeds intake Shift of K+ into cells

   Hyperkalaemia occurs when the serum potassium levels are above 5.5 mmol/L, which can result in arrhythmias. Muscle cramps, muscle weakness, rhabdomyolysis, myoglobinuria are presenting signs and symptoms in hyperkaliemia.

  •   Increase in the difference in the amount of potassium between ICF & ECF

  •   Increased difference reduces the excitability of cells

  •   Cell membranes especially nerves & muscles are less responsive to normal stimuli

  •    Fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria

  •    decreased bowel motility

  •       Paresthésies, leg camps, ↓ BP, iléus

  •       abdominal distention, hypoactive reflexes,

  •       ECG: flattened T waves, prominent U waves, - ST depression, prolonged PR interval

  * most serious: lethal ventricular. arrhythmias; cardiac arrest

  •       Fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria

  •       decreased bowel motility

  •       paresthésies, leg camps, ↓ BP, ileus

  •       abdominal distention, hypoactive reflexes,

  •       ECG: flattened T waves, prominent U waves,

                                  - ST depression, prolonged PR interval

           * most serious: lethal ventricular

                arrhythmias; cardiac arrest

  Calcium

  Calcium has a significant physiological role in the body. It is involved in skeletal mineralization, contraction of muscles, the transmission of nerve impulses, blood clotting, and secretion of hormones. The diet is the predominant source of calcium. It is mostly present in the extracellular fluid. Absorption of calcium in the intestine is primarily under the control of the hormonally active form of vitamin D, which is 1,25-dihydroxy vitamin D3. Parathyroid hormone also regulates calcium secretion in the distal tubule of kidneys. Calcitonin acts on bone cells to increase the calcium levels in the blood.

  •       Hypocalcaemia diagnosis requires checking the serum albumin level to correct for total calcium, and the diagnosis is when the corrected serum total calcium levels are less than 8.8 mg/dl, as in vitamin D deficiency or hypoparathyroidism. Checking serum calcium levels is a recommended test in post-thyroidectomy patients.

  •        Hypercalcemia is when corrected serum total calcium levels exceed 10.7 mg/dl, as seen with primary hyperparathyroidism. Humoral hypercalcemia presents in malignancy, primarily due to PTHrP secretion. Oral calcium with Vitamin D , be given 30 minutes before meals (improve GI absorption)

  •       Avoid giving calcium & bicarbonate in the same solution (precipitate will form)

  •       IV calcium diluted in D5W

  Bicarbonate

  The acid-base status of the blood drives bicarbonate levels. The kidneys predominantly regulate bicarbonate concentration and are responsible for maintaining the acid-base balance. Kidneys reabsorb the filtered bicarbonate and also generate new bicarbonate by net acid excretion, which occurs by excretion of both titrable acid and ammonia. Diarrhea usually results in loss of bicarbonate, thus causing an imbalance in acid-base regulation. 

  Magnesium

  Magnesium is an intracellular cation. Magnesium is mainly involved in ATP metabolism, contraction and relaxation of muscles, proper neurological functioning, and neurotransmitter release. When muscle contracts, calcium re-uptake by the calcium-activated ATPase of the sarcoplasmic reticulum is brought about by magnesium.] Hypomagnesemia occurs when the serum magnesium levels are less under 1.46 mg/dl. It can present with alcohol use disorder and gastrointestinal and renal losses—ventricular arrhythmias, which include torsade’s de pointes seen in hypomagnesemia. 

  Chloride

  Chloride is an anion found predominantly in the extracellular fluid. The kidneys predominantly regulate serum chloride levels. Most of the chloride, which is filtered by the glomerulus, is reabsorbed by both proximal and distal tubules (majorly by proximal tubule) by both active and passive transport

  Hyperchloremia can occur due to gastrointestinal bicarbonate loss. Hypochloremia presents in gastrointestinal losses like vomiting or excess water gain like congestive heart failure. 

  Phosphorus

  Phosphorus is an extracellular fluid cation. Eighty-five percent of the total body phosphorus is in the bones and teeth in the form of hydroxyapatite; the soft tissues contain the remaining 15%. Phosphate plays a crucial role in metabolic pathways. It is a component of many metabolic intermediates and, most importantly of adenosine triphosphate (ATPs) and nucleotides. Phosphate is regulated simultaneously with calcium by Vitamin D3, PTH, and calcitonin. The kidneys are the primary avenue of phosphorus excretion. 

  Phosphorus imbalance may result due to three processes: dietary intake, gastrointestinal disorders, and excretion by the kidneys

  
  

  Complications

  Both hyponatremia and hypernatremia, as well as hypomagnesemia, can lead to neurological consequences such as seizure disorders. 

  Hypokalemia and hyperkalemia, as well as hypocalcemia, are more responsible for arrhythmias.

  Bicarbonate imbalance can lead to metabolic acidosis or alkalosis.

  Clinical Significance

  Some of the common causes of electrolyte disorders seen in clinical practices are:

  ·         Hyponatremia: low dietary sodium intake, primary polydipsia, SIADH, congestive heart failure, hepatic cirrhosis, failure of adrenal glands, hyperglycemia, dyslipidemia

  ·         Hypernatremia: unreplaced fluid loss through the skin and gastrointestinal tract, osmotic diuresis, hypertonic saline administration

  ·         Hypokalemia: hyperaldosteronism, loop diuretics 

  ·         Hyperkalemia: increase release from cells as in metabolic acidosis, insulin deficiency, beta-blocker or decreased potassium excretion as in acute or chronic kidney disease, aldosterone deficiency or resistance

  ·         Hypercalcemia: malignancy, hyperparathyroidism, chronic granulomatous disease

  ·         Hypocalcaemia: acute pancreatitis, parathyroid hormone deficiency after thyroidectomy, neck dissection, resistance to parathormone, hypomagnesemia, sepsis 

  ·         Hypermagnesemia: increase oral magnesium intake

  ·         Hypomagnesemia: renal losses as in diuretics, alcohol use disorder, or GI losses as in diarrhea

  ·         Bicarbonate level: increases in primary metabolic alkalosis or compensation to primary respiratory acidosis - decreases in primary metabolic acidosis or compensation to primary respiratory alkalosis.

  ·         Hyperchloremia: normal saline infusion

  ·         Hypochloremia: GI loss as in diarrhea, renal losses with diuretics

  ·         Hypophosphatemia: refeeding syndrome, vitamin D deficiency, hyperparathyroidism

  ·         Hyperphosphatemia: hypoparathyroidism, chronic kidney disease

   

  
  

  • LEARNING RESOURCES

  • Topic 10 : Fluid and Electrolytes Imbalances Collaboration Care and Nursing Management Using The Nursing Process Book

    Mark as done
  • KNOWLEDGE CHECK ACTIVITIES

  • Topic 10 Discussion Forum

    Mark as done

    Students, please answer the questions posted in this forum. 

    
    

  • REFERENCES

    Sara, L., Justine, H. & Hayley, G. (2020). The Royal Marsden Manual of Clinical Nursing Procedures (10th ed). United States: John Wiley and Sons Ltd

    Sutherland-Fraser. S., Menna, D., Brigid, M. G. & Benjamin, L. (2020). Perioperative Nursing : An Introduction (3rd ed). Australia: Elsevier

    LeMone, P. & Burke, K.M. (2019). LeMone and Burke's Medical-Surgical Nursing : Clinical Reasoning in Patient Care. (7th ed.). USA: Pearson

    Baranoski, S. (2020). Wound Care Essentials :Practice Principles (5th ed). USA: Wolters Kluwer Health

    Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.).Philadelphia: Wolters Kluwer Health.

  
• Topic 11 : Fluid and Electrolytes Imbalances Collaboration Care and Nursing Management Using The Nursing Process [Part 2]

                                               TOPIC 11

  Fluid and electrolytes imbalances collaborative care and nursing management using the nursing process:
  • Acid-base imbalances
  • Respiratory acidosis/alkalosis
  • Metabolic acidosis/alkalosis

  Introduction

  Acid–base imbalance is an abnormality of the human body's normal balance of acids and bases that causes the plasma pH to deviate out of the normal range (7.35 to 7.45).

  Learning outcome

  At the end of session, participants will be able to:

    1 Explain Acid -base imbalances

  2 Explain Respiratory acidosis/alkalosis

     3   Explain Metabolic acidosis/alkalosis

   https:// youtu.be/VMxmDeduKR0

  Facts and Definitions

    1.Acid-base homeostasis is necessary to maintain life.

     2.Acid base balance must be within a definite range for cellular function to occur.

     3.The acidity of a substance, determined by the hydrogen ion (H⁺) concentration; is expressed as pH.

  4    Normal function of body cells depends on regulation of hydrogen ion concentration

     Hydrogen circulates throughout the body fluids in two forms

     Hydrogen circulates throughout the body fluids in two forms:

    1. The volatile H+ of carbonic acid

    2. The nonvolatile form of H+ inorganic acids (sulfuric, pyruvic, phosphoric & lactic   acid)

  ACID-BASE IMBALANCES

  ·  Patients with a number of clinical conditions frequently develop acid-base imbalances. The nurse must always consider the possibility of acid-base imbalance in patients with serious illnesses.

  ·  Normally the body has three mechanisms by which it regulates acid-base balance to maintain the arterial pH between 7.35 and 7.45. These mechanisms are the buffer system, the respiratory system, and the renal system

     The buffer system is the fastest acting system and the primary regulator of  acid base balance.

    The lungs help maintain a normal pH by excreting CO₂ and water, which are by-products of cellular metabolism.

   The three renal mechanisms of acid elimination are secretion of small amounts of free hydrogen into the renal tubule, combination of H⁺ with ammonia (NH₃) to form ammonium (NH₄⁺), and excretion of weak acids.

  Alterations in Acid-Base Balance

    Acid-base imbalances are classified as respiratory or metabolic. Respiratory imbalances affect carbonic acid concentrations; metabolic imbalances affect the base bicarbonate.

  ·  Respiratory acidosis (carbonic acid excess) occurs whenever there is hypoventilation.   Respiratory alkalosis (carbonic acid deficit) occurs whenever there is hyperventilation.

    Metabolic acidosis (base bicarbonate deficit) occurs when an acid other than carbonic acid accumulates in the body or when bicarbonate is lost from body fluids.

  ·   Metabolic alkalosis (base bicarbonate excess) occurs when a loss of acid (prolonged vomiting or gastric suction) or a gain in bicarbonate occurs.

  ·  Arterial blood gas (ABG) values provide valuable information about a patient’s acid-base status, the underlying cause of the imbalance, the body’s ability to regulate pH, and the patient’s overall oxygen status.

    In cases of acid-base imbalances, the clinical manifestations are generalized and nonspecific. The treatment is directed toward correction of the underlying cause

  Acid Base Balance:

                                  RATE AT WHICH                     RATE AT WHICH

                                  ACIDS / BASES        =              ACIDS / BASES

                                  ARE PRODUCED                      ARE EXCRETED

  This balance results in a stable concentration of Hydrogen ions (H⁺) and it is

  this concentration that is called pH

  pH value: Normal value is 7   < 7:          Acidic

                                                       > 7:          Alkaline

                                  Arterial Blood:        7.35 – 7.45

    At pH 7.35 – 7.45: 

      Cell wall /membrane integrity is maintained

        Speed of cellular enzymatic actions is maintained

                      Acid-Base Regulation through the:

                                  1. Chemical buffering system

                                  2. Biological buffering system

                                  3. Physiological buffering system       

    THESE BUFFER SYSTEMS ABSORB OR RELEASE H⁺ IONS TO CORRECT

  ACID BASE BALANCE

  
  

  1. Chemical Buffering System

  This system is in the ECF It is called Carbonic Acid-Bicarbonate Buffer System .This system is the first to react to pH changes in the ECF. This System reacts within seconds

  cellular metabolism--CO2 is produce  ------

    As CO₂ is produced, H⁺ ions increased If CO₂ not removed by the Lungs,the following takes place

  CO₂ + H₂O   ............   H₂CO₃         ........        H⁺   +      HCO₃

  Carbon + Water Carbonic Acid  Hydrogen+bicarbonate      dioxide                                                                   ion

  Carbonic Acid -Bicarbonate Buffer System

  This is the largest buffer system in the Extracellular Fluid

  PHYSIOLOGICAL BUFFERING SYSTEM

      There are 2 physiological buffering systems:    LUNGS

      KIDNEYS                                                                                              

     3.1  Lungs:    Act rapidly to an Acid-Base Imbalance (before the biological system)

   When concentration of H+ alter, the rate and depth of respiration will

      alter:Eg: 

  Metabolic Acidosis     Rate of respiration is increased     More CO₂ exhaled

               <7    pH returns to 7 acidity corrected

  Metabolic Alkalosis      Rate of respiration is decreased CO₂ retained

               pH returns to 7  Alkalinity corrected

  3.2 Kidneys:    Kidneys take from a few hours to several days to regulate acid-base  balance

  When pH <7           Kidneys reabsorb HCO₃ pH is corrected

  When pH >7           Kidneys excrete HCO₃         pH is corrected

  When H⁺>               Kidneys excrete H⁺ ions by:  

                                  a) combining H⁺ and PO₄^3- to form Phosphoric Acid H₃PO₄

       Phosphoric acid is then excreted in the urine

                             b) Amino acid is changed to Ammonia in the renal tubules

     Ammonia combines with H to form Ammonium     Ammonium is then excreted in the urine

  DISTURBANCES IN ACID BASE BALANCE

  Checking Acid-Base Balance in a Client:  

    Arterial Blood Gas Analysis (ABG)

  Parameters of Measurement in ABG:    1. pH

                                                                         2. PaCO₂

                                                                          3. PaO₂

                                                                         4. O₂ Saturation

                                                                          5. Base Excess

                                                                           6. HCO₃

  pH:    Measures H+ concentration in the body fluids

  PaCO₂      Partial pressure of CO₂ in the artery (reflects depth of pulmonary     ventilation)

                  Normal value:    35-45mm Hg

     < 35-45 mm Hg      Hyperventilation has occurred

           > 45 mm Hg         Hypoventilation has occurred

  PaO₂      Partial pressure of O₂ in arterial blood

                  Normal value:  80-100mm Hg  

   < 60mm Hg     Lead to anaerobic metabolism >    Lactic acid production > Metabolic Acidosis                 

                   > 100mm Hg    Hypoxemia

  Oxygen Saturation:      Arterial Hemoglobin saturated with O₂

                                                              Normal Value:        95% - 100%              

  HCO₃:      Excreted and reabsorbed by the Kidneys to maintain Acid-Base Balance

                  Principle Buffer in the ECF

                  Normal Value:                        22 – 26 mEq/L

                   < than 22-26mEq/L               Metabolic Acidosis

                         > than 22-26mEq/l                Metabolic Alkalosis

  TYPES OF ACID-BASE IMBALANCES:

     1. Respiratory Acidosis: Carbonic Acid Excess

    2.  Respiratory Alkalosis : Carbonic Acid Deficit

    3. Metabolic Acidosis: Bicarbonate Deficit

    4. Metabolic Alkalosis : Bicarbonate Excess

   PaCO2

  •   Carbonic acid level is measured by PaCO2 value of the blood

  •       partial pressure of CO2 in the arterial blood

  •       normal value: 35 – 45 mm Hg

  Bicarbonate ( HCO3)

  •       The most abundant base in the body fluids

  •       Metabolic end product of fats and carbohydrates

  •       Normal serum value 22 – 26 mmHg

           ACID - BASE IMBALANCE

                  Classifications

      1.     Acidosis or alkalosis

              a. Acidosis: Hydrogen ion concentration in blood   increases above normal and pH is   below 7.35

              b. Alkalosis: Hydrogen ion concentration in blood decreases below normal and   pH is above 7.45

  Analysis of Arterial Blood Gases

  Step1: Classify the Arterial Gas

                                  Normal:  7.35 – 7.45

                                  Acidosis: below 7.35

                                  Alkalosis: above 7.45 

  Step 2: Assess PaCO2

                             Normal: 35 – 45 mmHg

                             Respiratory Acidosis: above 45 mmHg

                              Respiratory Alkalosis: below 35 mmHg               

  Step 3: Assess HCO3

                                  Normal: 22 –26 mEq/L

                                  Metabolic Acidosis: below 22 mEq/L

                                  Metabolic Alkalosis: above 26 mEq/L

   

  Step 4 : classify degree of compensation

                                   pH is normal: fully compensated

                                    pH is not normal: partially   compensated

  Respiratory acidosis

  Respiratory acidosis is a condition that occurs when your lungs can’t remove all of the carbon dioxide produced by your body. This causes the blood and other body fluids to become too acidic.

  •       pH < 7.35

  •       pCO₂ > 45 mm Hg (excess carbon dioxide in the blood)

  •       Respiratory system impaired and retaining CO₂ causing acidosis

  Causes of respiratory acidosis

  ·         Airway diseases, such as asthma and COPD

  ·         Lung tissue diseases, such as pulmonary fibrosis, which causes scarring and thickening of the lungs

  ·         Diseases that can affect the chest, such as scoliosis

  ·         Diseases that affect the nerves and muscles that signal the lungs to inflate or deflate

  ·         Medicines that suppress breathing, including narcotics (opioids), and "downers," such as benzodiazepines, often when combined with each other or alcohol

  ·         Severe obesity, which restricts how much the lungs can expand

  ·         Obstructive sleep apnea

  ·         Chest deformities, such as kyphosis ,

  ·          Chest injuries, Chest muscle weakness, Long-term (chronic) lung disease

  ·         Neuromuscular disorders, such as myasthenia gravis, muscular dystrophy

  • Overuse of sedative drugs, causing decreased respiration

  a Acute respiratory failure from airway obstruction

    b. Over-sedation from anesthesia or narcotics

      c. Some neuromuscular diseases that affect ability to use chest muscles

     d. Chronic respiratory problems, such as Chronic Obstructive Lung Disease

  Signs and Symptoms of respiratory acidosis

  a.  Compensation s/s: kidneys respond by   generating and reabsorbing bicarbonate ions,

        so HCO₃ >26 mm Hg

   b. Respiratory: hypoventilation, slow or shallow respirations

   c. Neuro: headache, blurred vision, irritability, confusion – cerebral vessels dilate

   d. Respiratory collapse leads to unconsciousness              and cardiovascular collapse

   e Confusion, Fatigue, Lethargy, Shortness of breath, Sleepiness

   Management respiratory acidosis

  Therapeutic measures that may be lifesaving in severe hypercapnia and respiratory acidosis include endotracheal intubation with mechanical ventilation and noninvasive positive pressure ventilation (NIPPV) techniques such as nasal continuous positive-pressure ventilation (NCPAP) and nasal bilevel ventilation.

  Early recognition of respiratory status and treat cause

     B.      Restore ventilation and gas exchange

                                  -CPR for respiratory failure with oxygen

                                   supplementation

                                  -intubation and ventilator support if indicated

     C.   Treatment of respiratory infections 

                                   -bronchodilators; antibiotic therapy

     D.  Reverse excess anesthetics and narcotics

                                   - naloxone (Narcan)

       E Continue respiratory assessments- monitor arterial blood gas (ABG) results

     Chronic respiratory conditions:

      Breathe in response to low oxygen    levels –

  Adjusted to high carbon dioxide level   through metabolic compensation (therefore, high CO₂ would not trigger breathing)

  -Treat with no higher than 2 liters O₂ per cannula (carbon dioxide narcosis)

  Drug treats respiratory acidosis

  Respiratory Acidosis Medication: Beta2 Agonists, Anticholinergics, Respiratory, Xanthine Derivatives, Corticosteroids, Benzodiazepine Toxicity Antidotes, Opioid Antagonist

  Interpret these ABG results

  pH - 7.25 - acidic

  PaCO2 – 50mmHg - acidic

  HCO3 – 22 mEq/L – normal

  - Respiratory acidosis, uncompensated

  pH - 7.37 - normal

  PaCO2 - 60 mmHg- acidic

  HCO3 - 38 mEq/L - alkaline

  - respiratory acidosis, fully compensated with metabolic alkalosis

  Acidosis https://youtu.be/-4HwKsDgf7Y

  Respiratory alkalosis

  Respiratory alkalosis is a condition marked by a low level of carbon dioxide in the blood due to breathing excessively

  • ppH >7.45
  • CO₂ < 35 mm Hg
  • Carbon dioxide deficit, secondary to hyperventilation

  Causes:

  Respiratory alkalosis may be produced as a result of the following causes:

  Hyperventilation with anxiety from:

             - uncontrolled fear, pain, stress (e.g. women in labor, trauma victims)

           -High fever.    Stress^[1]

            Mechanical ventilation during anesthesia

  ·         Pulmonary disorder^[3]

  ·         Thermal insult^[6]

  ·         High altitude areas^[7]

  ·         Salicylate poisoning (aspirin overdose)^[7]

  ·         Hyperventilation (due to heart disorder or other, including improper mechanical ventilation)^[1][8]

  ·         Vocal cord paralysis (compensation for loss of vocal volume results in over-breathing/breathlessness).^[9]

  ·         Liver disease^[7]

  ·         drugs cause respiratory alkalosis

  ·         Iatrogenic causes of respiratory alkalosis include medications like progesterone, methylxanthines (e.g., theophylline), salicylates (also cause primary metabolic acidosis), catecholamines and nicotine as well as excessive minute ventilation provided by mechanical ventilation (especially in chronic obstructive pulmonary

  • Over breathing (hyperventilation)
  • Central nervous system (brain) abnormalities

  The diagnosis of respiratory alkalosis is done via test that measure the oxygen and carbon dioxide levels (in the blood), chest x-ray and a pulmonary function test ,

  There are two types of respiratory alkalosis: chronic and acute as a result of the 3–5 day delay in kidney compensation of the abnormality.^[13][3]

  ·         Acute respiratory alkalosis occurs rapidly, have a high pH because the response of the kidneys is slow.^[14]

  ·         Chronic respiratory alkalosis is a more long-standing condition, here one finds the kidneys have time to decrease the bicarbonate level.^[14]         

  
  

  Signs and Symptoms:

  Compensation: Kidneys-eliminating bicarbonate ions

                          HCO3<22mmHg

  Respiratory-hyperventilating :shallow,rapid breathing

  Neuro-panicked,light-headed.tremors-may develop tetany.numb hands and feet (carpopedal) r/t symptoms of hypocalcemia
  

  (elevated pH more Ca ions are bound to serum albumin and less ionized “active” calcium available for nerve and muscle conduction)

  •       seizures, loss of consciousness - due to cerebral constriction

  •       Cardiac: (H+ pulled from the cells in exchange of K+ -hypokalemia)

                                  - palpitations, sensation of chest tightness

                                  - ECG changes

  Management of Respiratory Alkalosis

          Encourage client to breathe slowly in a   paper  bag to rebreathe CO₂

        * Breathe with the patient

       * Provide emotional support and reassurance               

      * Anti-anxiety agents

       * Sedation

  •       On ventilator, adjustment of ventilation settings (decrease rate and tidal volume)

  •         Prevention

                                  - pre-procedure teaching

                                   -  emotional support

                                   - monitor blood gases 

            

   

  Metabolic Acidosis   https://youtu.be/0Er2a9-OxGc

            Deficit of bicarbonate in the blood

  •       pH <7.35

  •       NaHCO₃ <22 mEq/L

  Causes of Metabolic Acidosis

  •       Caused by an excess of acid, or loss of bicarbonate from the body

  •       Acute lactic acidosis from tissue hypoxia:

          (lactic acid produced from anaerobic metabolism with shock, cardiac arrest)

  •       Ketoacidosis:

     (fatty acids are released and converted to ketones when fat is used to supply glucose        needs as in uncontrolled Type 1 diabetes or starvation)

  •       Acute or chronic renal failure

            (kidneys unable to regulate electrolytes)

  •        Excessive bicarbonate loss (severe diarrhea, intestinal suction, bowel fistulas)

  •       results from other disease and often accompanied by electrolyte and fluid imbalances

  •       Hyperkalemia often occurs as hydrogen ions enter cells to lower pH and K+ enter intravascular

    Signs and Symptoms

  •       Compensation s/s:

          -  increase the depth and rate of respiration (an effort to lower the CO₂ in    the blood    paCO₂ <35 mm Hg)

  •       Neuro changes: (electrolytes imbalance)

                          - headache, weakness, fatigue, confusion, stupor and coma

  •       Cardiac: dysrhythmias and possibly cardiac arrest from hyperkalemia

  •       GI: anorexia, nausea, vomiting

  ·                         Hyperventilating., Shortness of breath.

  ·                       Fatigue., Chronic exhaustion.

             Headaches., Drowsiness. , Confusion. Dizziness

  ·                     Sweating, Breathlessness.

  ·                       Numbness and /or tingling in your fingertips, toes and lips.

  ·                     Irritability. , Nausea. , Muscle spasms or twitching

  Nursing Diagnoses:

                  a.             Decreased Cardiac Output

                  b.             Risk for Excess Fluid Volume

                  c.              Risk for Injury

  Metabolic Acidosis   https://youtu.be/0Er2a9-OxGc

            Deficit of bicarbonate in the blood

  •       pH <7.35

  •       NaHCO₃ <22 mEq/L

  Causes of Metabolic Acidosis

  •       Caused by an excess of acid, or loss of bicarbonate from the body

  •       Acute lactic acidosis from tissue hypoxia:

          (lactic acid produced from anaerobic metabolism with shock, cardiac arrest)

  •       Ketoacidosis:

     (fatty acids are released and converted to ketones when fat is used to supply glucose        needs as in uncontrolled Type 1 diabetes or starvation)

  •       Acute or chronic renal failure

            (kidneys unable to regulate electrolytes)

  •        Excessive bicarbonate loss (severe diarrhea, intestinal suction, bowel fistulas)

  •       results from other disease and often accompanied by electrolyte and fluid imbalances

  •       Hyperkalemia often occurs as hydrogen ions enter cells to lower pH and K+ enter intravascular

    Signs and Symptoms

  •       Compensation s/s:

          -  increase the depth and rate of respiration (an effort to lower the CO₂ in    the blood    paCO₂ <35 mm Hg)

  •       Neuro changes: (electrolytes imbalance)

                          - headache, weakness, fatigue, confusion, stupor and coma

  •       Cardiac: dysrhythmias and possibly cardiac arrest from hyperkalemia

  •       GI: anorexia, nausea, vomiting

  ·                         Hyperventilating., Shortness of breath.

  ·                       Fatigue., Chronic exhaustion.

             Headaches., Drowsiness. , Confusion. Dizziness

  ·                     Sweating, Breathlessness.

  ·                       Numbness and /or tingling in your fingertips, toes and lips.

  ·                     Irritability. , Nausea. , Muscle spasms or twitching.

   

  Nursing Diagnoses:

                  a.             Decreased Cardiac Output

                  b.             Risk for Excess Fluid Volume

                  c.              Risk for Injury

  Metabolic acidosis develops when too much acid is produced in the body. It can also occur when the kidneys cannot remove enough acid from the body. There are several types of metabolic acidosis:

  ·         Diabetic acidosis (also called diabetic ketoacidosis and DKA) develops when substances called ketone bodies (which are acidic) build up during uncontrolled diabetes.

  ·         Hyperchloremic acidosis is caused by the loss of too much sodium bicarbonate from the body, which can happen with severe diarrhea.

  ·         Kidney disease (uremia, distal renal tubular acidosis or proximal renal tubular acidosis).

  ·         Lactic acidosis.

  ·         Poisoning by aspirin, ethylene glycol (found in antifreeze), or methanol.

  ·         Severe dehydration.

  Lactic acidosis is a buildup of lactic acid. Lactic acid is mainly produced in muscle cells and red blood cells. It forms when the body breaks down carbohydrates to use for energy when oxygen levels are low.

  ·         Cancer

  ·         Carbon monoxide poisoning

  ·         Drinking too much alcohol

  ·         Exercising vigorously for a very long time

  ·         Liver failure

  ·         Low blood sugar (hypoglycemia)

  ·         Medicines, such as salicylates, metformin, anti-retrovirals

  ·         MELAS (a very rare genetic mitochondrial disorder that affects energy production)

  ·         Prolonged lack of oxygen from shock, heart failure, or severe anaemia

  ·         Seizures

  ·         Sepsis -- severe illness due to infection with bacteria or other germs

  ·         Severe asthma

  Metabolic Alkalosis       

                                                 

  
  

  
  

  
  

  
  

  •       pH >7.45

  •       HCO₃ > 26 mEq/L

   Causes of Metabolic Alkalosis

   Caused by a bicarbonate excess, due to loss of acid, or a bicarbonate excess in the body

  •     1  Loss of hydrogen and chloride ions through excessive vomiting, gastric suctioning, or excessive diuretic therapy

  •        2. Response to hypokalemia

  •        3. Excess ingestion of bicarbonate rich antacids or excessive treatment of acidosis with Sodium Bicarbonate

  •       The most common causes are volume depletion (particularly when involving loss of gastric acid and chloride (Cl) due to recurrent vomiting or nasogastric suction) and diuretic use. Metabolic alkalosis involving loss or excess secretion of Cl is termed chloride-responsive

  Signs and symptoms

  1 Compensation: Lungs respond by  decrease the depth and rate of respiration in effort to retainCO2 and increase pH

  2. Neuro: altered mental status, numbness and tingling around mouth, fingers,     toes, dizziness, muscle spasms (similar to hypocalcemia due to less ionized    calcium levels)

  3. Hypokalemia - H+ moves out of cell & K+ moves inside cell

  Metabolic Alkalosis Treatment & Management

  The management of metabolic alkalosis depends primarily on the underlying etiology and on the patient’s volume status. In the case of vomiting, administer antiemetics, if possible. If continuous gastric suction is necessary, gastric acid secretion can be reduced with H2-blockers or more efficiently with proton pump inhibitors. In patients who are o
  

  on thiazide or loop diuretics, the dose can be reduced or the drug can be stopped if appropriate. Alternatively, a potassium-sparing diuretic or acetazolamide can be added.

    1 Correcting underlying cause will often improve alkalosis

  2.Restore fluid volume and correct electrolyte imbalances (usually IV NaCl with KCL). 

   3.With severe cases, acidifying solution may be administered.

  Restore fluid volume and correct electrolyte imbalances (usually IV NaCl   with KCL)    With severe cases, acidifying solution may   be administered

  Metabolic alkalosis is corrected with the aldosterone antagonist spironolactone or with other potassium-sparing diuretics (eg, amiloride, triamterene). If the cause of primary hyperaldosteronism is an adrenal adenoma or carcinoma, surgical removal of the tumor should correct the alkalosis.

  Correcting underlying cause will often   improve alkalosis

              Nursing Diagnoses:

      a.    Impaired Gas Exchange

       b. Ineffective Airway Clearance

       c. Risk for Injury

  Interpreting results

  •       pH  - 7.5

  •       PaCO2  - 40 mmHg

    HCO3  - 30 mEq

  •       pH  - 7.5- alkalosis

  •       PaCO2  - 40 mmHg - normal

  •       HCO3  - 17 mEq/L   - metab alkalosis

  •        Metabolic alkalosis ,uncompensated

   

  Metabolic Acidosis

  Metabolic acidosis occurs when your body produces too much acid ,or your kidney  don't reproduces  

  What causes metabolic acidosis?

  The four leading causes of metabolic acidosis include:

    Diabetes-related acidosis. Diabetes-related acidosis develops when ketone bodies build up in your body from untreated diabetes. Your body produces ketone bodies while it turns (metabolizes) fats into energy. Your body uses ketone bodies for energy when sugars (glucose) aren’t available.

     Hyperchloremic acidosis. Hyperchloremic acidosis develops when your body loses too much sodium bicarbonate. It may occur if you take too many laxatives or have severe diarrhea.

      Lactic acidosis. Lactic acidosis develops when you have too much lactic acid in your body. Lactic acid is an organic acid that your muscle cells and red blood cells produce for energy when you don’t have a lot of oxygen in your body. Causes include liver failure, low blood sugar, alcohol use disorder, cancer and intense exercise.

     Renal tubular acidosis. Renal tubular acidosis develops when your kidneys don’t pass enough acids into your pee. As a result, your blood becomes more acidic.

  ·    Causes include untreated diabetes, the loss of bicarbonate in your body and kidney conditions. 

    Unmanageable diarrhea and kidney failure are the most common causes of metabolic acidosis. remove enough acids from your blood.

  Common signs and symptoms of metabolic acidosis include:

  ·         Accelerated heartbeat (tachycardia).

  ·         Confusion or dizziness.

  ·         Feeling very tired (fatigue).

  ·         Loss of appetite.

  ·         Headache.

  ·         Rapid breathing or long, deep breathing.

  ·         Nausea and vomiting.

  ·         Feeling weak.

  ·         Breath that smells sweet or fruity.

  
  

  View

  Dear students, please complete this quiz to test your understanding of Topic 11

  
  

  Interpret these ABG results:

  pH - 7.25

  PaCO2 – 50mmHg

  HCO3 – 22 mEq/L

  Answer

  pH - 7.25 – acidic

  PaCO2 – 50mmHg - acidic

  HCO3 – 22 mEq/L – normal

  - Respiratory acidosis, uncompensated

  Interpret these ABG results:

  pH - 7.37

  PaCO2 - 60 mmHg

  HCO3 - 38 mEq/L

  Answer

  pH - 7.37 - normal

  PaCO2 - 60 mmHg- acidic

  HCO3 - 38 mEq/L - alkaline

   - respiratory acidosis, fully compensated with metabolic alkalosis

  Blood and urine tests can help diagnose

  Interpret these ABG results:

  pH - 7.37

  PaCO2 - 60 mmHg

  HCO3 - 38 mEq/L

  Answer

  pH - 7.37 - normal

  PaCO2 - 60 mmHg- acidic

  HCO3 - 38 mEq/L - alkaline

   - respiratory acidosis, fully compensated with metabolic alkalosis

  Blood and urine tests can help diagnose

  Treatments include:

  • Sodium citrate if you have kidney disease or kidney failure.
  • Fluids delivered through a vein in your arm (IV fluids).
  • IV sodium bicarbonate, which helps balance the acids in your blood.
  • Insulin if you have diabetes-related acidosis.
  • Removing toxic substances from your blood, including aspirin, methanol (a substance in adhesives, paints and varnishes) or ethylene glycol (a substance in antifreeze) Inotropes help your heart beat stronger, which helps get more oxygen in your body and lowers the amount of acids in your blood. .

  Treatment plan, which may include medications and changes to your lifestyle

  • Monitoring your blood sugar closely.
  • Taking medicines as prescribed by your healthcare provider.
  • Eating low-acid, high-alkali foods.
  • Limiting the amount of alcohol, you consume.

  Prevention

  You can’t prevent metabolic acidosis. However, you can help reduce your risk

  • Drinking a lot of water and other fluids.
  • Managing your blood sugar levels if you have diabetes.
  • Reducing the amount of alcohol that you consume. Moderate alcohol consumption in men and people assigned male at birth (AMAB) is two drinks or fewer per day. In women and people assigned female at birth (AFAB), moderate        Severe cases may involve kidney or other organ failure and death

  What is the difference between metabolic acidosis and respiratory acidosis?

  Metabolic acidosis involves your digestive system and your urinary system. Your kidneys can’t properly filter acids from your bloodstream. Kidney disease, kidney failure, untreated diabetes, loss of bicarbonate and blood poisoning may cause a more acidic pH in your body.

  Respiratory acidosis involves your respiratory system. Your lungs can’t remove enough carbon dioxide from your bloodstream. Asthma, brain injuries and excessive or disordered substance use may affect your lungs’ ability to remove carbon dioxide. my risk of 

  Discussion  Forum

  View Make forum post 1

   Students, please answer the questions in this forum

  
  

  How can I reduce my risk of developing metabolic acidosis?

  What causes metabolic acidosis?

  Interpret these ABG results:

  •       Q1 pH - 7.5

  •       PaCO2 - 40 mmHg

  HCO3 - 30 mEq/L

  •       pH  - 7.5- alkalosis

  •       PaCO2  - 40 mmHg - normal

  •       HCO3  - 17 mEq/L   - metabolic  alkalosis

  •        Metabolic alkalosis, uncompensated

   

  Q2  pH - 7.38

  •       PaCO2 – 50 mmHg

  •       HCO3 – 35 mEq/L

  Answer Q2 pH - 7.38        - normal (acidosis)

  •       PaCO2 – 50 mmHg - acidosis

  •       HCO3 – 28 mEq/L    - alkalosis

  •       Respiratory acidosis, fully compensated with metabolic alkalosis

  •       Q 3 Ph   7.39                                           

  •       PaCO2 – 32 mmHg

  HCO3   -  20 mEq/ L

  •       Answer Q3 v Ph   7.39    - normal ( acidosis)         

  •       PaCO2 – 32 mmHg  - alkalosis

  •       HCO3   -  20 mEq/ L  - acidosis

  •       Metabolic acidosis, fully compensated with respiratory alkalosis

  •       Q 4 Ph 7.49

  •       PCO2 – 50 mmHg

  •       HCO3 – 32 mEq/L

  AnswerQ4  Ph 7.49       - ( abnormal) alkalosis

  •       PCO2 – 50 mmHg     - acidosis

  •       HCO3 – 32 mEq/L      - alkalosis

  •       Metabolic alkalosis, partially compensated with respiratory acidosis

   

  
  

  
  

  
  

  
  
  
• Topic 12 : Fluid and Electrolyte Replacement

                                                       TOPIC 12

                                Fluid and electrolytes replacement
  Introduction

  Hospitalized patients often have conditions that impair their ability to regulate their hydration status. Improper fluid management leads to significant morbidity and mortality. 

  In all cases, treatment is directed toward correction of the underlying cause.

  Mild deficits can be corrected using the appropriate oral rehydration or electrolyte solution. 

  Tonicity in living systems

  If a cell is placed in a hypertonic solution, water will leave the cell, and the cell will shrink. In an isotonic environment, there is no net water movement, so there is no change in the size of the cell. When a cell is placed in a hypotonic environment, water will enter the cell, and the cell will swell.

   

   

  At the end of session, participants will be able to:

  1.  Explain oral replacement of fluid

  2 Explain intravenous replacement of electrolytes

  Fluid management

  •   Oral Rehydration- safest and most effective treatment in alert clients/patients

                  - 1.500 ml / day

                  - 30 ml/kg body weight

  •    Intravenous Therapy if fluid deficit is severe clients unable to ingest fluids

  Tonicity   

   The osmolality of the solution

  •   Isotonic fluids - those with the same osmolality as the cell interior

                    Less than 270 mOsm/kg (mmol/kg)

   Hypotonic fluids - those that contain more water than the cell interior

                  275-295 mOsm/kg (mmol/kg)

  •   Hypertonic fluids - those that contain less           water than the cell interior

             More than 300 mOsm/kg (mmol/kg)

  Type of IV fluids

  INTRAVENOUS FLUID AND ELECTROLYTE REPLACEMENT

  ·  Fluid replacement therapy is used to correct many fluid and electrolyte imbalances. The amount and type of solution used is determined by patient requirements and laboratory results.

  ·  Hypotonic solutions, such as 5% dextrose in water and 0.45% NaCl, provide more water than electrolytes, diluting the ECF and producing movement of water from the ECF to the ICF.

  ·  Administration of an isotonic solution, such as lactated Ringer’s and 0.9% NaCl, expands only the ECF. There is no net loss or gain from the ICF.

  · A hypertonic solution initially raises the osmolality by the ECF and expands it, making them useful in the treatment of hypovolemia and hyponatremia.

  ·  KCl, CaCl, MgSO₄, and HCO₃^– are common additives to the basic IV solutions.

    Plasma expanders stay in the vascular space and increase the osmotic pressure.

  A.  CRYSTALLOIDS – solutions with small molecules that flow easily from the bloodstream into cells & tissues.

  1. Isotonic solution – has the same solute           concentration as another solution

    ex: Normal Saline, Lactated Ringer’s,  D₅W

  •       Normal Saline (0.9% Sodium Chloride)

                                  - expands intravascular volume

                                  - used with blood transfusion

                                  - replaces large sodium losses (burns)

                                  - replaces water lost from extracellular   fluid

  •       Lactated Ringer’s

                  - similar to plasma electrolytes except magnesium

                  - replaces fluid losses from burns and lower GIT

                  - Fluid of choice for acute blood loss

  •       D5 Water

                  - replaces water losses

                  - provides free water necessary for cellular   rehydration

                  - lowers serum sodium in hypernatremia

  Hypotonic solution – solutions that have lower osmolality (less than 275 mOsm/L) than body fluids.

          ex: 0.45% NaCl,

           0.33% NaCl,     D2.5% W, 0.225% , NaCl

  . Hypertonic solutions – solutions that have higher osmolality (greater than 295 mOsm/L) than body fluids

     ex: D5 NaCl, D5 0.45% NaCl

                                        D₅LR

                                        D10 Water

                                    3 % sodium chloride

  corrects serious sodium depletion

  •       D5 0.45% NaCl

      - DKA (glucose below 250mg/dl)

                                  D5 0.9% NaCl

                                  - hypotonic dehydration

                                  - SIADH

                                  - temp for shock before expanders

                                  - don’t use in cardiac & renal ds

                                  (pulmonary edema & heart failure)

  •       D10 W

                                  - for nutrition with glucose

                                  - water replacement

                                  - monitor serum glucose hyperglycemia            

   

  . COLLOIDS/ PLASMA EXPANDERS

                   – pulls fluid from the interstitial compartment into the vascular    compartment. ex: Albumin, Dextran

       Common symptoms of mild dehydration include:

  • dry mouth, thirst ,headache,dry eyes, dry, dark coloured urine, dizziness and, fatigue

     healthy adults can rehydrate by drinking:  water, clear broth, diluted juices, sports    drink

  ORS is a liquid solution. It’s designed to be consumed by mouth.

  If a person is unable to drink due to vomiting, nasogastric feeding might be used. This delivers the ORS via a nasogastric tube, which is inserted through the nose and into the stomach

  
  

  Date/ Time 3/3/23	Intake	mt	Output	Amt
  7 -3	juice  water  D5 Nacl	160   480   600	urine     vomitus     drainage from chest tube     diarrhea	750   50   100    150

  • Urine has been passed
  • Pulse is strong

  Evidence based practice

    Accurately recording intake and output is still an unreliable measure of actual fluid balance.

  Measuring daily weight is a better I/O chart

  The importance takes fluid replacement a priority when you're physically active. Drinking enough fluids will help to maintain your concentration and performance, increase your endurance, and prevent excessive elevations in heart rate and body temperature. It's all about sufficient hydration.

  Signs and Symptoms of Dehydration

  Severe Dehydration
  One or more danger signs:

  • Lethargic or unconscious
  • Absent or weak pulse
  • Respiratory distress

  OR at least two of the following:

  • Sunken eyes
  • Not able to drink or drinks poorly
  • Skin pinch goes back very slowly

  Some Dehydration
  No danger signs AND at least two of the following:

  • Irritable or restless
  • Sunken eyes
  • Rapid pulse
  • Thirsty (drinks eagerly)
  • Skin pinch goes back slowly

  No Dehydration
  Signs:

  • Awake and alert
  • Normal pulse
  • Normal thirst
  • Eyes not sunken
  • Skin pinch normal

  Rehydration

  Oral Rehydration Guidance: No to Some Dehydration

  • Give oral rehydration solution (ORS) immediately to dehydrated patients who can sit up and drink. If ORS is not available, you should provide water, broth, and/or other fluids. You should not provide drinks with a high sugar content, such as juice, soft drinks, or sports drinks, because they could worsen diarrhea.
  • Offer ORS frequently, measure the amount drunk, and measure the fluid lost as diarrhea and vomitus.
  • Give small, frequent sips of ORS to patients who vomit, or give ORS by nasogastric tube.
  • Make ORS with safe water, which is water that has been boiled or treated with household bleach or a chlorine product using the dose recommended in the product’s instructions, at least 15 minutes before adding prepackaged oral rehydration salts. To make the solution, mix the oral rehydration salts (a prepackaged sachet of glucose and electrolytes) with 1 liter of safe water.
  • A rough estimate of oral rehydration rate for older children and adults is 100 ml of ORS every 5 minutes, until the patient stabilizes.
  • The approximate amount of ORS (in milliliters) needed over 4 hours can also be calculated by multiplying the patient’s weight in kg by 75.
  • If the patient requests more than the prescribed ORS solution, give more.
  • Patients should continue to eat a normal diet or resume a normal diet once vomiting stops.
  • For infants: encourage the mother to continue breastfeeding.

  Assessment

  • Reassess the patient after 1 hour of therapy and then every 1 to 2 hours until rehydration is complete.
  • During the initial stages of therapy, while still dehydrated, adults can consume as much as 1,000 ml of ORS per hour, if necessary, and children as much as 20 ml/kg body weight per hour.
  • The volumes and time shown are guidelines based on usual needs. If necessary, you can increase the amount and frequency, or you can give the ORS solution at the same rate for a longer period to achieve adequate rehydration. Similarly, you can decrease the amount of fluid if the patient becomes hydrated earlier than expected.

  • severe dehydration,
  • stupor,
  • coma,
  • uncontrollable vomiting, or
  • extreme fatigue that prevents drinking.
  • For severe dehydration, start IV fluids immediately. If the patient can drink, give ORS by mouth while the IV drip is set up. Ringer’s lactate IV fluid is preferred. If not available, use normal saline or dextrose solution.
  • It is important to measure the amount of IV fluids delivered and measure the fluid lost as diarrhea and vomitus.

  Assessment

  • Reassess the patient every 15–30 minutes and continue hydrating. The volumes and time intervals shown are guidelines provided on the basis of usual needs.
  • If necessary, you can increase the rate of fluid administration, or you can give the fluid at the same rate for a longer period, to achieve adequate rehydration. If hydration is not improving, give fluids more rapidly; the patient may need 200 ml/kg or more of intravenous fluids during the first 24 hours of treatment.
  • You can decrease the amount of fluid if the patient becomes hydrated earlier than expected.
  • Give more than the prescribed ORS solution if the patient requests more.
  • Switch from intravenous hydration to oral rehydration solution once hydration is improved and the patient can drink. This will conserve IV fluids and reduce the risk of phlebitis and other complications.
  • You can use nasogastric tubes to administer oral rehydration solution if the patient is alert but unable to drink sufficient quantities independently.

  *Repeat once if radial pulse is still very weak or not detectable

  Signs of Adequate Rehydration

  • Skin goes back normally when pinched
  • Thirst has subsided

  •      indicator of fluid balance

  •      What factors affect accuracy of intake and output recording?

  •      What measures to take to ensure accurate daily weight measurements?

  Drip Rates

  •     Your patient needs an infusion of dextrose 5% in water at 125 ml/ hr. If the tubing set is calibrated at 15 gtt/ml, what’s the drip rate?

  Drip rate = total milliliters   x drops factor total minutes

  •      125 ml  x 15 gtt/ml

       60 mins

  •       1,875 gtts

        60 mins

  •       x = 31.25 gtt/min = 31 gtt/min

  Flow rate

  •      Your patient needs 250 ml of normal saline solution over 2 hrs. What’s the infusion rate?

  •      Total Volume ordered

        number of hours

  = 250 ml  

        2 hrs

  = 125 ml/hr

  Infusion Time

  •      I f you plan to infuse 1 liter of D5 W at 50 ml/hr, what’s the infusion time?

  •      Volume to be infused

              flow rate

  •      1 L = 1000 ml

  •      1000 ml     x =20hrs

    50 ml/hr

  Infusion Time

  •      Your patient requires 500 ml of normal saline solution at 80ml/hr. What’s the infusion time? If the normal saline solution is hung at 5 am, what time will the infusion end?

  •      X = 500 ml

      80 ml/hr

  = 11:15 a.m.

  Hypertonic saline is a crystalloid intravenous fluid composed of NaCl dissolved in water with a higher sodium concentration than normal blood serum. Both 3% and 5% hypertonic saline (HS) is currently FDA-approved for use in hyponatremia and increased intracranial pressure (ICP). Patients with hyponatremia with severe features should have their serum sodium gradually corrected with boluses of hypertonic saline. Patients should have their serum sodium monitored at regular intervals and can receive multiple boluses a day.[1]

   

  Hypertonic saline should be discontinued once the patient’s symptoms improve or they have an adequate increase in serum sodium. Cerebral edema and elevated intracranial pressure (ICP) are significant causes of morbidity and mortality in patients with intracranial tumors, cerebral hematomas, traumatic brain injuries, cerebral infarcts, and intracranial hemorrhages. Hypertonic saline increases the osmolarity of the blood, which allows fluid from the extravascular space to enter the intravascular space, which leads to decreases in brain edema, improved cerebral blood flow, and decreased CSF production. Research shows that 3% hypertonic saline decreases ICP similarly to 20% mannitol.[2] Both hypertonic fluids have similar effects on haemodynamics. Hypertonic saline leads to increases in serum sodium and has less of a diuretic effect than mannitol, likely due to the increased serum sodium causing ADH release. Hypertonic saline administered after mannitol in traumatic brain injury has also demonstrated improvement of cerebral oxygenation in addition to lowering ICP.[3]

  
  Due to there being no guidelines regarding the administration of hypertonic saline for increased ICP, various studies have used concentrations of 3% to 23.5% NaCl.[4]
  

  MCQ

  View

  Dear students, please complete this quiz to test your understanding of Topic 12

  
  
    Patient scenario
  

  1Your patient has had nausea, vomiting, and diarrhea for 4 days. The blood work shows this patient is dehydrated but their electrolytes have managed to stay within normal limits.

  A What kind of solution is this patient's blood?

  B What kind of fluid would you give this patient?

  2 Your patient comes in with bilateral +2 pitting edema on the lower extremities. The blood work confirms congestive heart failure (CHF).

  A What kind of solution is this patients’ blood?

   B What kind of fluid would you give this patient?

  3 Your patient is hypotensive, dizzy, weak, and reports abdominal pain. The blood work confirms adrenal insufficiency.

  A What kind of solution is this patient's blood?

   B What kind of fluid would you give this patient?

  
  

  
  

  1.  The extracellular fluid (ECF) and intracellular fluid (ICF) compartments in total body water are normally in a ratio of (ECF: ICF):

  a.       1:1

  b.       2:1

  c.       1:2

  d.       1:4

  2.       The dominant extracellular cation and anion are:

  a.       Sodium and bicarbonate

  b.       Potassium and chloride

  c.       Potassium and phosphate

  d.       Sodium and chloride

  3.       The dominant intracellular cation and anion are:

  a.       Sodium and bicarbonate

  b.       Potassium and phosphate

  c.       Sodium and chloride

  d.       Potassium and chloride

  4.       The recommended replacement for extracellular volume fluid loss is:

  a.       Isotonic (normal) saline solution

  b.       Dextrose and one-fourth normal saline solution

  c.       Dextrose and one-half normal saline solution

  d.       One-half normal saline solution plus 20 mEq potassium chloride per liter

  Answers:

  1. c.

  2. d.

   3. b.

   4. a  

  Answer MEQ  

    1A Hypertonic

  o     1B Isotonic at first such as 0.9% NaCl (expand their volume and give them more to move or shift around)

  o    Hypotonic second, usually 0.45% NaCl (shift the fluid into the cells)

  o   2A Hypotonic

  o    2B Hypertonic (shifts fluid out of the extracellular space and into the vein, to be filtered out in the kidneys)

  o    3A Isotonic

    Adrenal insufficiency leads to loss of volume and loss of sodium leaving the patient hypovolemic and hyponatraemic.

  3B Isotonic to help treat hypotension by expanding the volume of fluid in the veins

      

    

   

  References:

  Sara, L., Justine, H. & Hayley, G. (2020). The Royal Marsden Manual of Clinical Nursing Procedures (10th ed). United States: John Wiley and Sons Ltd

  Sutherland-Fraser. S., Menna, D., Brigid, M. G. & Benjamin, L. (2020). Perioperative Nursing : An Introduction (3rd ed). Australia: Elsevier

  LeMone, P. & Burke, K.M. (2019). LeMone and Burke's Medical-Surgical Nursing : Clinical Reasoning in Patient Care. (7th ed.). USA: Pearson

  Baranoski, S. (2020). Wound Care Essentials :Practice Principles (5th ed). USA: Wolters Kluwer Health

  Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.).Philadelphia: Wolters Kluwer Health.

  
  

  • TOPIC 13 Perioperative Procedures Lesson

    Mark as done
  • TOPIC 14 Folder

    Mark as done
  • Topic 14 Fluid and electrolytes imbalance procedures: Folder

    Mark as done
  
• Topic 13 : Fluid and Electrolytes Imbalance Procedures [Part 1]

  Fluid and electrolytes imbalance procedures:

  • Calculate intravenous infusion

  • Assisting with intravenous infusion

  • Care of intravenous infusion

  • Change intravenous infusion

  • Discontinue intravenous infusion

  • Measure and record of Intake & Output

  Introduction

  Inappropriate intravenous fluid therapy is a significant cause of patient morbidity and mortality and may result from either incorrect volume (too much or too little) or incorrect type of fluid. Fluid overload has no precise definition, but complications usually arise in the context of pre-existing cardiorespiratory disease and severe acute illness. Insufficient fluid administration is readily identified by signs and symptoms of inadequate circulation and decreased organ perfusion. Administration of the wrong type of fluid results in derangement of serum sodium concentration, which, if severe enough, leads to changes in cell volume and function, and may result in serious neurological injury. In patients whose condition is uncomplicated, we recommend a restrictive approach to perioperative intravenous fluid replacement, with initial avoidance of hypotonic fluids, and regular measurement of serum concentration of electrolytes, especially sodium.

  Electrolyte deficits   managed by replacement, while electrolyte excesses are treated by restricting additional intake of electrolytes and/or administering medications or fluids to decrease the electrolyte concentration.

   

  LEARNING OUTCOME

  At the end of the lecture, the students will be able to:
  
  1.Demonstrate the ability to reflect upoun   nursing practice for awareness and improvement

   2. Identify the importance of each procedures that would lead to overload, deficit, medical errors and complications.        

   

  Discussion

  View Make forum post 1

   Students, please answer the questions in this forum

  
  

  1 You are a staff nurse working am duty a few students approach you and ask you to check the calculation for iv infusion. During correction of their answer you found that the answers were wrong due to formula application. Explain to them the work out of the question so that no medical errors can occur.

  2 You are incharge in a medical ward and at the end of the shift you have to close all the patients with intake output chart, one of your patient intake output charts is not tally. What is the issue that you can gather in this situation?

  3 Are the students during their interm ship properly guided and new comers are given proper mentorship at the work place

  4 Are the new staffs there given a final test to check their competency skill before precedes to give intravenous infusion,

  Intravenous (IV) cannulation

   Intravenous (IV) cannulation is a technique in which a cannula is placed inside a vein to provide venous access. Venous access allows sampling of blood, as well as administration of fluids, medications, parenteral nutrition, chemotherapy, and blood products.

  IV cannulation Mistakes

  Tips and tricks in IV cannulation for difficult vein

  Best sites iv infusion location

  Medication errors are serious, but those associated with the IV route of administration often result in the most severe outcome

  Strict definitions of errors and direct observation methods allowed identification of errors at every step of the medication administration process that was evaluated.  IV infusion, continuous infusion, errors, intensive care unit, critical care can happen

  The World Health Organization (WHO) has defined an adverse event as “an injury related to medical.¹ In 1999, the US Institute of Medicine  the importance of preventable adverse events and patient safety, reporting that about 100 000 people die each year in the United States as a result of medical errors. 

  Medication errors have been documented as a major cause of preventable adverse events, which, in turn, are associated with substantial morbidity and mortality. Given that IV infusions in the ICU frequently involve high-risk medications such as insulin, vasopressors, sedatives, opioids, and concentrated electrolytes, concern about errors and adverse outcomes is warranted.

  Definition of Errors Associated with IV Infusions

  Type of Error	Definition
  Section A: Administration (direct observation of medication being administered to patient)
  Incomplete labelling of IV tubing	Tubing was labelled with only partial information (e.g., name of medication but no further details).
  Incorrect labelling of IV tubing	Labelling did not meet criteria that IV tubing be labelled with (1) type of medication being infused and (2) type of tubing (central or peripheral) at time of observation.
  Inappropriate Y-site or piggy-back	Products being infused together were not compatible or compatibility data to support the combination were lacking; precipitate was visible in infusion bag or IV tubing.
  Inappropriate infusion rate	Infusion rate programmed on pump was not appropriate for the type of tubing being used.
  Inappropriate concentration	Resulting concentration was inappropriate for the type of tubing being used.
  Inappropriate diluent	Type of solution used for dilution was inappropriate for type of IV access.
  Inappropriate IV access	Given the type of medication and resultant concentration, tubing was not appropriate for medication administration.
  Incomplete or incorrect labelling of infusion bag	Infusion bag was not labelled with the name of the medication, the concentration, and the date that the bag was prepared, or the bag was labelled incorrectly.
  Section B: Documentation (medication administration record [MAR])
  Concentration not recorded	Concentration was not recorded in MAR.
  Diluent not recorded	Diluent was not recorded in MAR.
  Infusion rate not recorded	Infusion rate was not recorded in MAR.
  Type of IV access not recorded	Type of IV access was not recorded in MAR.
  Medication not recorded	Infusion of medication was observed but not recorded in MAR.
  Incorrect tubing recorded	Tubing recorded in MAR differed from tubing observed in patient’s room.
  Incorrect diluent recorded	Diluent recorded in MAR differed from diluent observed in patient’s room.
  Incorrect infusion rate recorded	Infusion rate recorded in MAR differed from infusion rate observed in patient’s room.
  Section C: Prescription (patient’s medical chart)
  Medication being infused but not ordered	Difference was identified between physician’s orders and medication being infused.
  Medication ordered but not being infused	Difference was identified between medication ordered by the physician and patient’s therapy; specifically, medication ordered was not administered within the 4-h observation block (unless order specified otherwise).
  Incorrect dose administered	Difference was identified between dose ordered by the physician and dose being infused.
  Incorrect infusion rate only	Difference was identified between infusion rate ordered by the physician and infusion rate being used for administration.
  Incorrect diluent	Difference was identified between diluent ordered by the physician and diluent being used for infusion.

  Open in a separate window

   

  Type of Error	No. of Errors	% of Section	% of All Errors
  Section A: Administration (direct observation of medication being administered to patient)
  Incomplete labelling of IV tubing
  Incorrect labelling of IV tubing
  Inappropriate Y-site or piggy-back
  Inappropriate infusion rate
  Inappropriate concentration
  Inappropriate diluent
  Inappropriate IV access
  Incomplete or incorrect labelling of infusion bag
  Other: bag hanging but not connected and/or medication not being infused
  Subtotal for direction observations
  Section B: Documentation (medication administration record [MAR])
  Concentration not recorded
  Diluent not recorded
  Infusion rate not recorded
  Type of IV access not recorded
  Medication not recorded
  Discrepancy between MAR and direct observations*
  Subtotal for errors related to MAR
  Section C: Prescription (patient’s medical chart)
  Medication being infused but not ordered
  Medication ordered but not being infused
  Discrepancy between direct observations and patient’s chart†
  Subtotal for errors related to patient’s medical chart
  Total (all errors)		NA

  Open in a separate window

  NA = not applicable.

  ^*Errors included incorrect medication recorded, incorrect tubing recorded, incorrect diluent recorded, and incorrect infusion rate recorded.

  ^†Errors included incorrect medication being administered; incorrect dose being administered; incorrect infusion rate only; no route or rate specified in chart; no units for medication indicated; medication bag hanging, but medication not ordered and not being infused;

  Iv infusion calculation

  IV infusion Time calculation

  Complications of gaining I.V. may include infiltration, hematoma, an air embolism, phlebitis, extravascular drug administration, and intraarterial injection. Intraarterial injection is rarer, but as threatening.

  Infiltration

  Infiltration is the infusion of fluid and/or medication outside the intravascular space, into the surrounding soft tissue. Generally caused by poor placement of a needle or angiocath outside of the vessel lumen. Clinically, you will notice swelling of the soft tissue surrounding the IV, and the skin will feel cool, firm, and pale. Small amounts of IV fluid will have little consequence, but certain medications even in small amounts can be very toxic to the surrounding soft tissue.

  Hematoma

  A hematoma occurs when there is leakage of blood from the vessel into the surrounding soft tissue. This can occur when an IV angiocatheter passes through more than one wall of a vessel or if pressure is not applied to the IV site when the catheter is removed. A hematoma can be controlled with direct pressure and will resolve over the course of 2 weeks.

  Air Embolism

  Air embolism occurs as a result of a large volume of air entering the patient's vein via the I.V. administration set. The I.V. tubing holds about 13 CCs of air, and a patient can generally tolerate up to 1 CC per kilogram of weight of air; small children are at greater risk. Air embolisms are easily prevented by making sure that all the air bubbles are out of the I.V. tubing; fortunately, it is an extremely rare complication.

  Phlebitis and Thrombophlebitis Phlebitis and thrombophlebitis occur more frequently. Phlebitis is inflammation of the vein which occurs due to the pH of the agent being administered during the administration of the I.V, while thrombophlebitis refers to inflammation associated with a thrombus. Both are more common on the dorsum of the hand than on the antecubital facia and may occur especially in hospitalized patients where an I.V. may be in for several days, where use of an angiocatheter, as opposed to a needle, can increase the risk of phlebitis, as the metal needle is less irritating to the endothelium. (Needles are generally used for short term IV access of less than three hours, while angiocaths are used for longer periods of time.) The infusate itself may cause phlebitis and may be irritating to the skin. Older patients are also more susceptible to phlebitis
  

  Treatment is generally elevating the site, providing warm compresses and administering non-steroidal agents to the patient. Anticoagulants and antibiotics are usually not required.

  Extravascular Injection

  Extravascular injection of a drug may result in pain, delayed absorption and/or tissue damage (if the pH of the agent being administering is too high or too low). If large volumes have been injected and the skin is raised and looks ischemic, then 1% procaine should be infiltrated. Procaine is a vasodilator, which will improve the blood supply both to the area and improve venous drainage away.

  Intraarterial Injection

  An intraarterial injection occurs rarely, but is much more critical. The most important measure is prevention, by making sure that the needle is inserted in a vein. Remember that veins are more superficial than arteries. If you cannulate an artery, there should be a pumping of bright red blood back into your angiocath, which would not be seen when you cannulate a vein. Intraarterial injection frequently causes arterial spasm and eventual loss of limb, usuaIly from gangre
   In  the case of intraarterial injection, recognition is paramount; observe the color of the skin, observe capillary refill, and feel the radial pulse. Capillary refill, which is observed by squeezing a fingertip and then watching the red color return, reflects perfusion. If capillary refill is decreased, then perfusion to that extremity is decreased. Treatment: In the case of intraarterial injection, it is the intravenous drugs which pose severe problems, rather than the I.V. solution. Leave the needle in the artery, and slowly inject approximately 10 CCs of one percent procaine. Procaine is a vasodilator. It is slightly acidic, with a pH of 5, and will counter the alkaline drugs that were just administered. Following treatment, the patient must be hospitalized, and may often require a sympathetic nerve block. 
  

  An endarterectomy and heparinization may also be necessary to prevent further complications.

  Removal of PIVCs: 

  There is no evidence for routine replacement of PIVC unless clinically indicated. PIVC’s should be maintained with regular assessment and documentation of complications.

  The possible reasons for removal of PIVC’s include a number of complications which range from infiltration, extravasation, phlebitis, occlusion, dislodgement and migration. Once the child’s treatment is over, the PIVC should be removed to avoid any additional complications.

  • Perform hand hygiene
  • Prepare patient and caregiver
  • Perform hand hygiene and apply non-sterile gloves, carefully remove the adhesive dressing, holding the cannula in place at all times
  • Hold a piece of sterile gauze or cotton wool over the exit site but do not apply pressure
  • Slowly withdraw the cannula, maintaining a neutral angle with the child’s skin
  • Cover site with dressing e.g. pressure dot, cotton wool and tape or Band-Aid^™
  • Advise the child and family that the cotton wool and tape or Band-Aid should remain in situ for up to 24 hours
  • Remove gloves, perform hand hygiene
  • Dispose of waste according to clinical practice, perform hand hygiene
  • Document date and reason for removal. Ensure the device is also removed from the LDA in EMR. 

  Assessment

  Patient and IV site assessments should be done on a regular basis.

  PIVC assessment includes:

   Assessment of PIVC insertion site: Assessment is to include the catheter position, patency/occlusion, limb symmetry, any signs of phlebitis (erythema, tenderness, swelling, pain etc.)  pressure injuries, and for signs infiltration /extravation  injuries. Paediatric patients are considered a vulnerable patient population therefore, the PIVC insertion site should be checked hourly when continuous infusions or medications are running.

  Assessment of PIVC dressing and splints: check securement of the PIVC dressing and securement devices and ensure they remain clean, dry, and intact. Ensure the splint tapes are not too tight or restrictive and that the insertion site remains visible for assessment

  Assessment of IV lines, equipment and IV fluid infusions:

  If the patient is receiving continuous IV fluid infusion- observations of the IV site, type of fluid and volume infused, and accurate rate of infusion should be observed hourly and documented in the fluid balance flowsheet.

  If the patient no longer requires IV access for infusions, remove the cannula at the earliest to avoid complications.

  If the patient (inpatient setting) is having intermittent infusion, eight hourly assessments are a minimum. Unstable patients who have signs and symptoms of complications are to be assessed more frequently.

  , The nurse will assess the PIVC with each visit.

  Caregiver and patient education will be provided on the signs of injuries and the process of contacting the nurse.

  Management

  Administration of intravenous fluid, drug infusions or blood produ

  a) Continuous infusion of IV fluids

  Assessment and documentation of findings are to be completed hourly to determine effective delivery of prescribed medications and fluid. 

  Each bag of fluid is independently double checked, and a signed patient label is put on the bag.

  Check the solution is the prescribed one, the rate of infusion, and the amount infused is noted. 

  Document the infused volume: Hourly on fluid balance flowsheet (it is advised to clear the infusion pump hourly)

  Check the infusion site for any signs of complications and document the assessment findings hourly in fluid balance flowsheet

  Review the cumulative volume infused and fluid output as required based on patient’s clinical condition

  Infusion Pump Pressure

  Pressure limit defaults for intravascular infusion pumps are programmed by Biomedical Engineering, based on the manufacturer’s recommendations.

  Upper limit infusion pump pressure can be manually increased with clinical discretion to accommodate:

  Increased viscosity of the fluid being administered

  High rate of the fluid being administered

  Reduced diameter of the intravascular catheter

  Increased length of the intravascular catheter

  Increased level of patient activity

  If pump pressure exceeds the recommended limits, check the patency of the PIVC.

  Special consideration: Patients admitted to the Neonatal Unit should have line pressure documented within the Peripheral IV Cannula Lines, Drains, and Airway (LDA) tab. 

   

  b) Administration of bolus/loading doses:

  Administering drugs:

  Drugs administered via PIVC may be

  diluted into a bag of IV fluids

  added to the burette of an infusion set

  prepared for administration via a volumetric infusion pump

  in a syringe for use in a syringe driver

  administered directly as a bolus or push

  The most appropriate method should be selected depending on volume of diluent required, patient condition, fluid balance and intended rate of delivery.

   Drugs administered via:

  Burette of an infusion set: to dilute the drug in a smaller volume via burette giving system, hang the bag of infusion fluid and gradually open the roller camp to allow appropriate amount of diluent into the burette. Inject the prescribed drug into the burette via the additive port.

  Line B (of the Plum 360™ pump): Certain medications can be infused as a secondary infusion through a syringe or infusion bag via line B.

  Syringe driver: is recommended for children weighing less than 10kg. Draw up required volume of diluent in appropriate size syringe and then pull back the syringe plunger to enable you to inject the drug into the syringe using principles of aseptic technique.

  Infusion bag: Scrub the hub prior to access of additive port before injecting prepared drug into infusion fluid bag. Without contaminating the key part (spike)using a non-touch technique insert the spike of the administration set into the septum of the infusion bag.

  Attach a completed drug label detailing the drug, dose, diluent, volume of diluent, date, time and signature of the nurse and the staff who double checked. 

  Access PIVC only after scrubbing the hub.

  For intermittent infusions, IV lines which are disconnected are to be discarded between infusions. 

  Ensure the cannula is flushed with normal saline once the giving set is disconnected from the cannula.

  For Opioid infusion bolus refer to the specific guidelines: Children’s Pain Management Service (CPMS) (opioid infusion guideline)

  Flushing of PIVC’s

  If the cannula is to be accessed intermittently for the administration of medications or fluids, the cannula should be flushed prior to infusion or at least once a shift.

  Sterile 0.9% sodium chloride for injection should be used to flush a catheter. This must be prescribed as a medication.

  The optimal volume used for intermittent injections or infusions is unclear. The literature suggests the volume of flush should equal at least twice the volume of the catheter and add on devices and a minimum of 2mL normal saline flush is recommended.

  Use 10mL syringe for flushing to avoid excessive pressure and catheter rupture. Syringes with an internal diameter smaller than that of a 10mL syringe can produce higher pressure in the lumen and rupture the catheter. If resistance is felt during flushing and force is applied this may result in an infiltration or extravasation injury

  Use aseptic non-touch techniques including cleaning the access port (scrub the hub) vigorously for at least 15 seconds and allowing to dry prior to accessing the system.

  Flush the PIVC using a pulsatile flushing technique (push pause motion).

  Flush catheters:

  Immediately after placement

  Prior to and after fluid infusion (as an empty fluid container lacks infusion pressure and will allow blood reflux into the catheter lumen from normal venous pressure) or injection.

  Prior to and after blood drawing.

  Change of PIVC dressing and securement of cannula:

  Dressings to PIVC sites are the first line of defence against infection and dislodgements. The dressing must be kept secure, clean dry and intact.

  Indications for dressing change include when it becomes insecure or if there is blood or fluid leakage under the dressing.

  Determine the need for an assistant considering patient age, developmental level and family participation prior to the procedure.

  If patient is allergic to transparent film dressings, use sterile film dressing to be used and changed daily.

  Carefully remove the old dressing, always holding the cannula in place. Loosen the edge of the dressing/tape and remove 'low and slow' in the direction of hair growth, keeping it close to the skin surface while pulling it back over itself, and supporting the newly exposed skin with your other hand.

  Take the opportunity to thoroughly inspect the site of entry of the cannula for any sign of infection.

  Skin preparation use 2% chlorhexidine and 70% alcohol swab or solution for dressings.

  Cleanse the area around the catheter insertion site including under the hub using a pattern which will ensure entire area is covered.

  Allow skin preparation to air dry prior to applying any dressing, this allows the disinfectant to work.

  Consider placing a small piece of sterile cotton wool ball or gauze underneath the hub of the cannula to reduce pressure.

  If desired, place sterile tape over the hub of the device before placing the transparent dressing.

  Cover the cannula insertion site with sterile transparent semipermeable, occlusive dressing (e.g. Tegaderm™, IV 3000™) placed using an aseptic non-touch technique over the catheter. This will allow continuous observation of the site and to help stabilise and secure the catheter.

  IV board / splints are recommended to secure PIVC placed in or adjacent to areas of flexion. This will adequately immobilize the joint and minimise the risk of venous damage resulting from flexion.

  When using Splints, ensure these are positioned and strapped with the limb and digits in a neutral position to prevent injury from restricting blood or nerve supply and to prevent pressure sores.

  Inspect the splint at least daily and change if soiled by blood or fluid leakage.

  Cover with non-compression tubular bandage. Ensure there is a clear window where the cannula enters the skin- insertion site, so the site can be regularly viewed.

  the site is visible

  the child can't injure themselves, or be injured by the connections

  the child can't remove or dislodge the cannula

  tapes are not too tight or restrictive.

  Refer to Intravenous access–Peripheral guideline In Summary, when dressing a peripheral IV cannula ensure:

  If patient is allergic to transparent film dressings, use sterile film dressing to be used and changed daily.

  Carefully remove the old dressing, always holding the cannula in place. Loosen the edge of the dressing/tape and remove 'low and slow' in the direction of hair growth, keeping it close to the skin surface while pulling it back over itself, and supporting the newly exposed skin with your other hand.

  Take the opportunity to thoroughly inspect the site of entry of the cannula for any sign of infection.

  Skin preparation use 2% chlorhexidine and 70% alcohol swab or solution for dressings.

  Cleanse the area around the catheter insertion site including under the hub using a pattern which will ensure entire area is covered.

  Allow skin preparation to air dry prior to applying any dressing, this allows the disinfectant to work.

  Consider placing a small piece of sterile cotton wool ball or gauze underneath the hub of the cannula to reduce pressure.

  If desired, place sterile tape over the hub of the device before placing the transparent dressing.

  Cover the cannula insertion site with sterile transparent semipermeable, occlusive dressing (e.g. Tegaderm™, IV 3000™) placed using an aseptic non-touch technique over the catheter. This will allow continuous observation of the site and to help stabilise and secure the catheter.

  IV board / splints are recommended to secure PIVC placed in or adjacent to areas of flexion. This will adequately immobilize the joint and minimise the risk of venous damage resulting from flexion.

  When using Splints, ensure these are positioned and strapped with the limb and digits in a neutral position to prevent injury from restricting blood or nerve supply and to prevent pressure sores.

  Inspect the splint at least daily and change if soiled by blood or fluid leakage.

  Cover with non-compression tubular bandage. Ensure there is a clear window where the cannula enters the skin- insertion site, so the site can be regularly viewed.

  the site is visible

  the child can't injure themselves, or be injured by the connections

  the child can't remove or dislodge the cannula

  tapes are not too tight or restrictive.

  Refer to Intravenous access–Peripheral guideline In Summary, when dressing a peripheral IV cannula ensure:

  it is secure

  for steps involved in accessing and securing the cannula http://www.rch.org.au/clinicalguide/guidelineindex/Intravenous_access_Peripheral/

  Documentation shall contain information on the insertion site, gauge of the needle and date and time of insertion has been documented in the EMR- LDA properties.

  Change of Extension sets

  Extension sets are to be changed when the access device is changed or immediately upon suspected contamination or when any break in integrity.

  Extension sets are to be primed and attached to the cannula at the time of IV insertion using an aseptic non-touch technique

  When exiting the flushing of extension set you must use a positive pressure clamping technique.

  When not in use, extension sets must be clamped

  IV Fluid Considerations via Peripheral IV line

  Which Fluids and how much fluids to use

  Refer to the Intravenous Fluids Clinical Practice Guideline: Intravenous Fluids

  Administering fluids containing glucose concentration greater than 12.5% will require central venous line access due to the risk of vascular endothelial damage.

  Labeling infusions:

  Label the fluid bag/syringe with date, time, patient name and signature of two checking staff.

  Label IV line if multiple lines are running: label close to the fluid bag or syringe or below the drip chamber.

  If additives are added to infusion, please label the bag or syringe driver with additives added.

  it is secure

  for steps involved in accessing and securing the cannula http://www.rch.org.au/clinicalguide/guidelineindex/Intravenous_access_Peripheral/

  Documentation shall contain information on the insertion site, gauge of the needle and date and time of insertion has been documented in the EMR- LDA properties.

  Change of Extension sets

  Extension sets are to be changed when the access device is changed or immediately upon suspected contamination or when any break in integrity.

  Extension sets are to be primed and attached to the cannula at the time of IV insertion using an aseptic non-touch technique

  When exiting the flushing of extension set you must use a positive pressure clamping technique.

  When not in use, extension sets must be clamped

  IV Fluid Considerations via Peripheral IV line

  Which Fluids and how much fluids to use

  Refer to the Intravenous Fluids Clinical Practice Guideline: Intravenous Fluids

   

  Administering fluids containing glucose concentration greater than 12.5% will require central venous line access due to the risk of vascular endothelial damage.

  Labeling infusions:

  Label the fluid bag/syringe with date, time, patient name and signature of two checking staff.

  Label IV line if multiple lines are running: label close to the fluid bag or syringe or below the drip chamber.

  If additives are added to infusion, please label the bag or syringe driver with additives added.

  Approved label can be generated by the EMR. 

  1.Changing IV bags and lines     

   

   

  What happens if intake and output are not equal?

  Intake and output (I&O) indicate the fluid balance for a patient. The goal is to have equal input and output. Too much input can lead to fluid overload. Too much output can cause dehydration

  What is the purpose of maintaining accurate intake and output fluid balance?

  Maintenance of fluid balance is an important activity and is essential for optimal health. If a patient has too much or too little fluid, this imbalance can cause health problems. There are some pathophysiological conditions that can result in fluid overload, such as kidney disease and some types of heart disease

  Professional Issues   
  

  Dehydration and fluid overload can both present as challenges for patients. For this reason, it is important that nurses understand how to measure and monitor fluid balance as well as the role that fluid plays in maintaining homeostasis. The Nursing and Midwifery Council (NMC) (2018) highlight the need to prioritise people and meet their individual hydration needs, while ensuring that the nurse has sufficient knowledge to assess and respond to physical needs.

  The NMC (2018) also highlight the importance of accurate record-keeping, this includes the recording of a patient's fluid balance. Incorrect recording of actual or potential fluid balance disturbances could lead to incorrect management. This could result in fluid overload dehydration and/or electrolyte disturbances (Pinnington et al, 2016).

  If patients oral/enteral intake is inadequate or they have lost a significant amount of fluid, this will need to be replaced with intravenous (IV) fluid (National Institute for Health and Care Excellence (NICE), 2017). It is the role of the nurse to administer and mange IV fluids for patients. Most commonly used replacement fluids are crystalloids and colloids, which have different effects on a range of important physiological parameters. Crystalloid solutions contain low-molecular-weight salts or sugars, which dissolve in water and freely pass between the intravascular space and the interstitial and intracellular spaces (Powell-Tuck et al, 2011). Colloids contain larger molecules that are unable to cross capillary membranes. Colloid solutions largely remain in the intravascular space (Macintosh, 2011). It is important that the nurse understands why a patient needs IV fluids and is able to regularly assess if IV fluids need to be continued. NICE (2017) recommends that decision-making is supported with daily biochemistry investigations including urea, creatinine and electrolytes.

  Assessment of fluid status

  Why fluid intake and output are monitored so carefully in hospital settings?

  Hospitalized patients often have conditions that impair their ability to regulate their hydration status. Improper fluid management leads to significant morbidity and mortality. Thoughtful consideration of the type and amount of fluid required for each patient is crucial

   What is the importance of maintaining fluid intake?

  Why do patients need their fluid balance monitored?

  Maintaining the correct balance of fluid is crucial to health and the function of vital organs. Illness can alter this balance. Monitoring your fluid balance helps us to monitor acute illness and allows us to avoid dehydration and other unwanted complications

  Why is it important to monitor fluid output?

  Monitoring fluid intake/output (fluid cycle) is critical to either diagnose or prevent complications. For example, heart failure patients must track their liquid intake and output volume to ensure they are not retaining liquid in the body

  References

  References Bekhof, J., van Asperen, Y., & Brand, P.L. (2013). Usefulness of the fluid balance: A randomized controlled trial in neonates

  Journal of Paediatrics and Child Health, 49(6), 486-492. doi:10.1111/jpc.12214 Cavari, T., Pitfield, A.F., & Kissoon, N. (20130b013e3182aa4e2a Craw). Intravenous maintenance fluids revisited. Pediatric Emergency Care, 29(11), 1225-1228. doi:10.1097 /PEC
  
  

  R

   

   

  
  
  
• Topic 14 : Fluid and Electrolytes Imbalance Procedures [Part 2]

  Fluid and electrolytes imbalance procedures:

  • Prepare and assist in setting up of Central Venous Line (CVL)

  • Perform Central Venous Pressure reading Output
  
  

  Introduction

  Many healthcare practitioners inserts central lines. Central line placement is essential in caring for many critically ill and hospitalized patients. Like any procedure, it has its complications, some of which can be life-threatening. Complications of central line placement include pneumothorax, hematoma, bleeding, infection, and extravasation. Understanding this procedure's proper technique and potential complications can help minimize central line-associated complications and improve clinical outcomes. This activity reviews the indications, techniques, possible complications, and ways to reduce the risk of complications associated with central line placement to increase healthcare provider knowledge and ability of the procedure and improve clinical outcomes.

    With ultrasound guidance, standardized techniques, new catheter designs, and central line care bundle, this procedure has become ubiquitous in the intensive care unit.

  LEARNING OUTCOME

  At the end of the lecture, the students will be able to:
  
  1.Demonstrate the ability to reflect upoun   nursing practice for awareness and improvement

   2. Identify the importance of each procedures that would lead early and late complications.      

  Indications for placing a CVL include the following:

  Drug infusions that could otherwise cause phlebitis or sclerosis (e.g., vasopressors and hyperosmolar solutions)

  Monitoring

  Central venous pressure

  Central venous oxyhemoglobin saturation (ScvO2)

  Pulmonary artery pressure

  Emergency venous access (due to difficult peripheral intravenous access)

  Transvenous pacing wire placement

  High-volume/flow procedures requiring large-bore access (haemodialysis and plasmapheresis)

  Vena cava filter placement

  Venous thrombolytic therapy

  What are 5 indications for central lines?

  Indications for central venous access via the subclavian approach to the subclavian vein include the following:

  ·         Volume resuscitation.

  ·         Emergency venous access.

  ·         Nutritional support.

  ·         Administration of caustic medications (eg, vasopressors)

  ·         CVP monitoring.

  ·         Transvenous pacing wire introduction.

  ·         Haemodialysis

  Complications of CVL placements include arterial puncture, catheter malposition, pneumothorax, subcutaneous hematoma, hemothorax, and cardiac arrest (exceedingly rare). The use of real-time ultrasound guidance can significantly decrease the complication rates of this procedure

  Periprocedural Complications

  Pneumothorax is a severe complication of subclavian and internal jugular vein catheter placements. However, the internal jugular approach is associated with a lower rate of pneumothorax

  . Venous air embolism, though potentially fatal, is an infrequent complication of this procedure and can be minimized by correctly positioning the patient and using diaphragms that prevent significant air embolism.

   Arterial puncture and injury are severe complications of this procedure, and every effort should be made to avoid their occurrence. As stated above, consistent use of real-time ultrasonography can prevent this complication.

  If arterial trauma and cannulation occur, endovascular treatment is the best approach to minimize hematoma, airway obstruction, stroke, and false aneurysm 

  If inadvertent arterial cannulation with a catheter occurs, it is better to leave the catheter in place and attempt treatment with a percutaneous closure device.

   Ventricular arrhythmias are known complications of this procedure and are related to the placement of the guidewire and catheter tip beyond the Cavo atrial junction Careful monitoring of the guidewire length as it is advanced into the vessel and determining adequate catheter length before securing it can avoid this potentially lethal

  Late Complications

  Catheter-related bloodstream infections (CR-BSI) are well-recognized complications of this procedure and are associated with increased morbidity and mortality for the patient the most critical risk factor for these infections is a longer duration of use, especially in dialysis patients Sequalae of CR-BSI include metastatic infections to vertebral bone or disc space, endocarditis, and endovascular infections.  

  Central vein stenosis is another late complication of this procedure and is most prominent in chronic haemodialysis patients who often undergo repeated cannulations of the central veins. The highest risk of this complication occurs in the left-sided internal jugular or subclavian vein cannulations. Other risk factors include using haemodialysis catheters instead of flexible triple-lumen catheters and a longer duration of catheter-dwelling time.

   In addition to central venous stenosis, catheter-related deep vein thrombosis (DVT) can also occur. Catheter-related DVT is most common in patients with underlying malignancy and using peripherally inserted multi-lumen catheters. The below-mentioned table summarizes the early and late complications associated with central venous line placement.

  Complications Associated with Central Venous Placement
  Early	Bleeding Arterial puncture Arrhythmia Air embolism Thoracic duct injury Mispositioning of catheter Pneumothorax Haemothorax
  Late	Infection Venous thrombosis Central vein stenosis Pulmonary embolism Venous stasis Catheter malfunction Catheter migration Catheter   perforation Nerve injury

   

  Bleeding Arterial puncture Arrhythmia Air embolism Thoracic duct injury Mispositioning of catheter Pneumothorax Haemothorax

  Enhancing Healthcare Team Outcomes

  Central line placement is a common, often bedside, procedure. Placement under strict sterile conditions and subsequent catheter management, as well as a daily review of the need for continuing the central catheter, can help minimize complications associated with this procedure.

  This requires an interprofessional team of clinicians and nurses. The critical care nurse must perform daily dressing inspections, periodically change the dressing following strict aseptic technique to prevent catheter-related infections, and report back to the clinician managing the case if any concerns arise, so corrective action(s) can be taken. An aseptic technique is also required when accessing the ports of the CVL. 

  Depending on the line's location, complications like pneumothorax, hematoma, bleeding, or extravasation can occur and should be monitored. Healthcare workers should generally avoid lines in the groin for more than 24 to 48 hours as they are prone to infections and make it difficult for the patient to ambulate or get out of bed. To ensure good practice and limit complications, most hospitals now have an interprofessional team of healthcare professionals in charge of central line insertion and monitoring, each checking and communicating any issues noted to the rest of the team so corrective action can occur if necessary. This universal practice has been shown to limit complications and optimize clinical outcomes for patients undergoing this procedure. In the event of an infection, an infectious disease specialty pharmacist may be consulted to best target antimicrobial therapy. 

  What are the problems with central venous line?

  Complications included failure to place the catheter (22 percent), arterial puncture (5 percent), catheter malposition (4 percent), pneumothorax (1 percent), subcutaneous hematoma (1 percent), hemothorax (less than 1 percent), and cardiac arrest (less than 1

  What are signs of CVC problems?

  If you notice any of these signs of infection, tell your doctor or nurse right away:

  Signs of infection, clotting, or other problems include:

    Redness, tenderness, drainage, warmth, or odor around the catheter site.

  Fever of 100.5F (38 C) or greater, or chills.

    Swelling of the face, neck, chest, or arm on the side where your catheter is inserted.

  · Leakage of blood or fluid at the catheter site or the cap

  Yellow or green drainage.

  Pain or discomfort.

  What is the most common cause of central catheter infection?

  Approximately 40%–80% of CRBSIs are caused by gram-positive organisms. Coagulase-negative Staphylococci, Staphylococcus aureus, and Enterococcus are the most common organisms. Methicillin-resistant staphylococcus is frequently seen

  What is the responsibility of central line nurses?

  Central Line Nursing is the insertion, care, and maintenance of Central Line Catheters by trained nurses. Highly skilled nurse specialists typically will place the Central Lines, lines that end in a large vein above or below the heart, and other nurses will be responsible for the care and maintenance of the lines

  How do you care and maintain central lines?

  
  
  

  Preventing a Problem with a Central Line

  ·         Wash your hands before doing any central line care and wear gloves.

  ·         Always keep a clean and dry dressing over the central line site.

  ·         Follow the instructions for cleaning the cap and using sterile equipment.

  ·         Avoid tugs or pulls on the central line

  What instructions should you give a patient who has a central ?

  
  

  
  

  
  

  
  

  Keep the central line dry. The catheter and dressing must stay dry. Don't take baths, go swimming, use a hot tub, or do other activities that could get the central line wet. Take a sponge bath to avoid getting the central line wet, unless your healthcare provider tells you otherwise.

  Why is it important to flush a central line?

  A CVAD should be flushed as often as your doctor tells you, to keep it clear of blood and prevent clotting. If it ends in more than one line (lumen), flush them in the same order each time. Depending on the type you have, you will flush it with either heparin or saline solution

  How do you ensure accuracy of CVP reading?

  To ensure accurate central venous pressure (CVP) readings, make sure that the manometer base is aligned with the patient's right atrium (the zero-reference point). The manometer set usually contains a leveling rod to allow you to determine this alignment quickly.

  What happens if CVP is high?

    Elevated CVP will present clinically as a pulsation of the internal jugular vein when a patient is inclined at 45 degrees; however, it can be noted in an upright patient in severe cases. Elevated CVP is indicative of myocardial contractile dysfunction and/or fluid retention.

     What happens if CVP is low?

    Low CVP can occur with hypovolemia or a fall in effective circulating volume, as occurs with distributive shock. Cardiogenic shock (or fluid overload) can result in an elevated CVP, because forward failure of the cardiac pump results in backup of blood within the venous side of the system

    

  
  

  
  

  
  

  Clinical points for consideration:

  ·  A chest X-ray should be performed immediately for the internal jugular and subclavian lines to ensure proper placement and the absence of an iatrogenic pneumothorax. 

    Be sure you withdraw venous blood before dilation and cannulation of the vessel.  

    Never force the guidewire on insertion because it may cause damage to the vessel or surrounding structures. Forcing the wire could also cause it to kink, making removal difficult and causing damage to the vessel wall. It may also lead to an inaccurate position of the catheter. 

   Always place your finger over the open hub of the needle to prevent an air embolism.

  ·  Always confirm placement with ultrasound, looking for reverberation artefact of the needle and tenting of the vessel wall. Needles cannot be visualized on ultrasound. Wires can be visualized so the operator can also confirm at that step.

    A venous blood gas can be aspirated off a femoral line to ensure it is not arterial.

  Contraindications

  Contraindications for central venous access are always relative and dependent on the urgency and alternative venous access.

   Site-specific contraindications include distorted local anatomy, skin infection overlying the insertion site, thrombus within the intended vein, or the presence of other indwelling intravascular hardware within the intended vessel.

   Coagulopathy and bleeding disorders are considered relative contraindications even when they are severe. A systematic review studying the risk of complications following CVL placement in patients with moderate-to-severe coagulopathy and thrombocytopenia revealed that the incidence of major bleeding complications is low, and evidence supporting the correction of coagulopathy before CVL placement is lacking. [15] Ultrasound-guided placement of CVL is the method of choice in patients at high risk of bleeding due to underlying disorders of haemostasis, as it allows for safe and reliable access to central veins with low rates of complications and lesser attempts in patients with these disorders

  Why measure the CVP line?

  CVP is an indicator of right ventricular and, to a lesser extent, left ventricular preload. CVP also reflects the limit to venous return and informs about right ventricular function. As such, CVP measurements may be helpful to guide fluid management.

   recorded at the end of expiration

     measured by transducing the waveform of a central venous line

   electronic transducer placed & zeroed at the level of the RA (the “phlebostatic axis” – usually the 4th intercostal space in the mid-axillary line is used)

  USES OF RAISED CVP

  ·         Right ventricular failure

  ·         Tricuspid stenosis or regurgitation

  ·         Pericardial effusion or constrictive pericarditis

  ·         Superior vena caval obstruction

  ·         Fluid overload

  ·         Hyperdynamic circulation

  ·         High PEEP settings

  What is the greatest risk for individuals with central venous access devices?

  Infection. One of the most serious complications of VADs is infection, including bacterial endocarditis. Central devices, including PICCs, carry greater risk of infection because they are open to the larger veins of the body. Tunneled catheters have lower infection rates and ports risk even fewer infections

   

  What are the risks and benefits of central line placement?

  It makes blood draws easier and allows for the delivery of large amounts of fluid for medication or hydration. Some types of central lines can remain in place for weeks or even months. A central line is very useful. However, it's not without risks, including the potential for infection, a collapsed lung, and more.7 F

  When inserting a catheter, one should use maximal sterile-barrier precautions, including a mask, a cap, a sterile gown, sterile gloves, and a large sterile drape. This approach has been shown to reduce the rate of catheter-related bloodstream infections and to save an estimated $167 per catheter inserted

  How do you take care of a central line?

  Preventing a Problem with a Central Line

  1.      Wash your hands before doing any central line care and wear gloves.

  2.      Always keep a clean and dry dressing over the central line site.

  3.      Follow the instructions for cleaning the cap and using sterile equipment.

  4.  Avoid tugs or pulls on the central line

  5.  What happens if central line is in right atrium?

  6.   What are the mechanical complications after central venous Catheterisation?

  7.      Major mechanical complications (major bleeding, arterial catheterisation, symptomatic arrhythmia, pneumothorax, and persistent nerve injury) typically require acute treatment or invasive intervention, in combination with prolonged observation of the patient.

    What are the most common central line infections?

     Coagulase-negative Staphylococci, Staphylococcus aureus, and Enterococcus are the most common organisms. Methicillin-resistant staphylococcus is frequently seen.

  What is a common complication of central venous catheter?

  The most common complications occurring during CVC application are: hearth arrhythmias, artery puncture, improper position of CVC and hematomas at the place of catheter insertion. If the top of the catheter enters the right heart chambers, it can cause heart arrhythmias by touching the hearth structures

  The 5 Most Common Central Venous Catheter Complications

  • Damage to central veins
  • Pulmonary, or lung, complications
  • Cardiac, or heart, complications
  • Device dysfunction
  • Infection

  What is the most common complication of central line?

  Vascular complications: The vascular complications seen during a central line insertion are arterial injury, venous injury, bleeding, and hematoma formation [14]. Ultrasound guidance has been shown to greatly reduce the risk of vascular complication

  How long do you keep dressing on after central line removal?

  Dressing Care
  
  The original dressing should be left in place for at least 48 hours, as long as it is not soiled or loose. If the dressing becomes soiled or loose, it must be changed. After 48 hours, all dressings can be removed if the site has scabbed underneath

  What are the types of potential complications of a Central Line?

  ·         Central Line-Associated Bloodstream Infection (CLABSI) ...

  ·         Collapsed Lung (Pneumothorax) ...

  ·         Delayed Pneumothorax (after 24 hours) ...

  ·         Artery Puncture. ...

  ·         Nerve or Vein injury. ...

  ·         Blood Clot (Thrombus) ...

  ·         Air Bubble in the Blood (Air Embolism) ...

  ·         Irregular Heartbeat

  Discussion Forum

  View Make forum post 1

   Students, please answer the questions in this forum

  
  

  1 What are the nursing responsibilities for central line insertion?

  2 What are the problems with central line insertion? 

  3 How can you prevent complications of central venous catheterization?

  4 Discuss strategies to overcome infection occur for patients with CVP line?

  REFERENCES

  1. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003; 348:1123–33. [PubMed] [Google Scholar]