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

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 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.

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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

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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 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.

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 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 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.

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   

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

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