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Fundamental Nursing Chapter 16 Fluid and Chemical Balance

Fundamental Nursing Chapter 16 Fluid and Chemical Balance. Infusion Monitoring and Maintenance. Regulating the Infusion Rate

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Fundamental Nursing Chapter 16 Fluid and Chemical Balance

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  1. Fundamental NursingChapter 16Fluid and Chemical Balance

  2. 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.

  3. 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).

  4. 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

  5. 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.

  6. Blood Administration • Blood is collected, stored, and checked for safety and compatibility before it is administered as a transfusion.

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. 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.

  12. Blood Transfusion Equipment • Catheter or Needle Gauge • it generally is infused through a 16- to 20-gauge—preferably an 18-gauge—catheter or needle.

  13. 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

  14. Figure 16-20 • Blood transfusion tubing.

  15. 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

  16. 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.

  17. 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)

  18. Figure 16-21 • Central venous catheter inserted into the subclavian vein and threaded into the superior vena cava.

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