Transcript Fundamental Nursing Fluid and Chemical Balance Chapter 16

Fundamental Nursing
Chapter 16
Fluid and Chemical
Balance
Infusion Monitoring and Maintenance

Regulating the Infusion Rate

The nurse is responsible for calculating, regulating,
and maintaining the rate of infusion according to
the physician's order. If an infusion device is used,
the electronic equipment is programmed in
milliliters per hour. If the solution is infused
without an electronic infusion device (i.e., by
gravity), the rate is calculated in drops (gtt) per
minute. Formulas for calculating infusion rates are
provided in Box 16-5.
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Assessing for Complications

Complications associated with the infusion of IV
solutions (Table 16-7) are circulatory overload
(intravascular volume that becomes excessive),
infiltration (escape of IV fluid into the tissue),
phlebitis (inflammation of a vein), thrombus
formation (stationary blood clot), pulmonary
embolus (blood clot that travels to the lung),
infection (growth of microorganisms at the site or
within the blood stream), and air embolism (bubble
of air traveling within the vascular system).
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Caring for the Site

Because the venipuncture is a type of wound,
it is important to inspect the site routinely. The
nurse documents its appearance in the client's
record. A common practice is to change the
dressing over the venipuncture site every 24 to
72 hours
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Replacing Equipment

Solutions are replaced when they finish
infusing or every 24 hours, whichever occurs
first (Skill 16-4). IV tubing is changed every
72 hours, depending on agency policy, with
some exceptions.
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Blood Administration

Blood is collected, stored, and checked for
safety and compatibility before it is
administered as a transfusion.
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Blood Collection and Storage

Blood donors are screened to ensure they are
healthy and will not be endangered by the
temporary loss in blood volume. Refrigerated
blood can be stored for 21 to 35 days, after
which it is discarded.
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Blood Safety

Once collected, the donated blood is tested for
syphilis,
hepatitis,
and
human
immunodeficiency virus (HIV) antibodies to
exclude administering blood that may transmit
these blood-borne diseases.
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Blood Compatibility

Antigens determine the characteristic blood
group—A, B, AB, and O—and Rh factor. Rh
positive means the protein is present; Rh
negative means the protein is absent.
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
Before donated blood is administered, the
blood of the potential recipient is typed and
mixed, or cross-matched, with a sample of the
stored blood to determine whether the two are
compatible. To avoid an incompatibility
reaction, it is best to administer the same blood
group and Rh factor.
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Blood Transfusion

Before administering blood, the nurse obtains
and documents the client's vital signs to
provide a baseline for comparison should the
client have a transfusion reaction.
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Blood Transfusion Equipment

Catheter or Needle Gauge

it generally is infused through a 16- to 20gauge—preferably an 18-gauge—catheter or
needle.
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
Blood Transfusion Tubing
Blood is administered through tubing referred
to as a Y-set (Fig. 16-20).
 The normal saline always is administered before
the blood is hung and follows after the blood has
been infused. It also is used during the infusion if
the client has a transfusion reaction

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Figure 16-20 • Blood transfusion tubing.
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Transfusion Reactions

Serious transfusion reactions generally occur
within the first 5 to 15 minutes of the infusion,
so the nurse usually remains with the client
during this critical time
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Total Parenteral Nutrition

Total parenteral nutrition (TPN; hypertonic
solution of nutrients designed to meet almost
all caloric and nutritional needs) is preferred
for clients who are severely malnourished or
may not be able to consume food or liquids for
a long period.
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
Because TPN solutions are extremely
concentrated, they must be delivered to an area
where they are diluted in a fairly large volume
of blood. This excludes peripheral veins. TPN
solutions are infused through a catheter
inserted into the subclavian or jugular vein; the
tip terminates in the superior vena cava. This
type of a catheter is referred to as a central
venous catheter (Fig. 16-21)
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Figure 16-21 • Central venous
catheter inserted into the
subclavian vein and threaded into
the superior vena cava.
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