 Human cells can exist only in a balanced environment. ◦ Cells are enclosed by a cell membrane.  Small compounds can pass through easily.  Larger charged compounds need assistance. ◦ Cell membrane is phospholipid bilayer.  Allows selective permeability

 Total body water (TBW) is 60% of adult weight ◦ Intracellular fluid (ICF): 45% ◦ Extracellular fluid: 15%  Interstitial fluid  Intravascular fluid  Fluids are composed of solutions (solvent and solute).

 Electrolytes ◦ Carry charges ◦ Reactive and dangerous if left to circulate  Water stabilizes electrolytes charges. ◦ Cation: positively charged ◦ Anion: negatively charged

 Electrolytes (cont’d) ◦ Measured by milliequivalent (mEq)  1 mEq of a cation can react completely with 1 mEq of an anion. ◦ Singly charged: monovalent ◦ Doubly charged: bivalent

 Electrolytes (cont’d) ◦ Sodium: regulates distribution of water ◦ Potassium: major role in neuromuscular function and conversion of glucose into glycogen  Sodium-potassium pump helped by insulin and epinephrine  Hypokalemia: low serum levels  Hyperkalemia: high serum levels

 Electrolytes (cont’d) ◦ Calcium: needed for bone growth  Hypocalcemia: low serum levels  Hypercalcemia: high serum levels ◦ Magnesium metabolizes proteins and carbohydrates.

 Electrolytes (cont’d) ◦ Bicarbonate: determines metabolic acidosis and alkalosis ◦ Chloride: regulates the pH of the stomach ◦ Phosphorus: important component in adenosine triphosphate (ATP)  ATP: the body’s energy source

 A healthy body maintains a balance between intake and output of fluids and electrolytes. ◦ Homeostasis: internal environment’s resistance to change ◦ A healthy person loses approximately 2 to 2.5 L of fluid daily.

 Dehydration is an inadequate total systemic fluid volume. ◦ Causes:  Diarrhea  Vomiting  Gastrointestinal drainage  Infections  Metabolic disorders

 Overhydration occurs when the body’s systemic fluid volume increases. ◦ Causes:  Unmonitored IVs  Kidney failure  Water intoxication in endurance sports  Prolonged hypoventilation © Medical-on-Line/Alamy Images

 Each bag of IV solution is individually sterilized. ◦ Altering IV concentration can move water into or out of fluid compartment

 IV solutions are categorized by their tonicity. ◦ Isotonic: same concentration of sodium as cell ◦ Hypertonic: greater concentration of sodium ◦ Hypotonic: lower concentration of sodium

 Oxygen-carrying solutions ◦ Whole blood is the best replacement for lost blood. ◦ Synthetic blood substitutes are being researched.

 Intravenous (IV) therapy involves cannulation of a vein with a catheter. ◦ Keep the IV equipment sterile!

 Assembling your equipment ◦ Gather and prepare in advance  Elastic tourniquet  Cleaning wipe or solution  Gauze  Tape or adhesive bandage  Appropriate size IV catheter  IV administration set

 Choosing an IV solution ◦ Usually limited to normal saline and LR solution ◦ IV solution bags must be used within 24 hours once opened. ◦ IV bags come in different fluid volumes.

 Choosing an administration set ◦ Must be used once piercing spike is exposed ◦ Number indicates number of drops it takes for a milliliter of fluid to pass into the drip chamber  Microdrip set: 60 gtt/mL  Macrodrip set: 10 or 15 gtt/mL © Jones & Bartlett Learning.

 “Six rights” of medication administration ◦ Right patient ◦ Right drug ◦ Right dose ◦ Right route ◦ Right time ◦ Right documentation

 Obtain order from Physician.  Understand the physician's orders.  Repeat any orders for verification.  Ask the patient about medication allergies.

 Verify the proper medication and prescription. ◦ Read the drug label three times.  When it is in the original box  When preparing the drug  Before administering  Verify form, dose, and route of medication.

 Check the expiration date and condition of the medication.  Confirm medication compatibility.  Dispose of syringes and needles safely.  Notify and advise the physician of any changes in the patient condition.

 Monitor the patient for adverse side effects.  Document actions and patient’s response. ◦ Name of the drug ◦ Dose of the drug ◦ Time administered ◦ Route of administration ◦ Name of person who administered the drug ◦ Patient’s response to the medication

 Standard precautions ◦ Treat any bodily fluid as being potentially infectious. ◦ Handwashing is an effective way to prevent the spread of disease.  Handwashing alone will not prevent infection.

 Disposal of contaminated equipment ◦ After an IV catheter or needle has penetrated a patient’s skin, it is contaminated.

 Disposal of contaminated equipment ◦ Immediately dispose of all sharps in a sharps container.

 Choosing an IV site ◦ Avoid areas that contain valves and bifurcations. ◦ Locate vein that looks straightest, firm, round, and springs when palpitated ◦ Limit IV access to distal areas of extremities. Courtesy of Rhonda Beck

 Choosing an IV site (cont’d) ◦ Bulging veins can roll from side to side.  Pull skin over vein taut with thumb of free hand.  Flex patient’s hand.  Stabilize wrist.

 Choosing an IV site (cont’d) ◦ Consider the patient’s opinion. ◦ Avoid extremity if it shows signs of:  Trauma  Injury  Infection ◦ Some protocols allow IV cannulation of leg veins.

 Choosing an IV catheter ◦ Over-the-needle: inserted over a hollow needle ◦ Butterfly: hollow, stainless steel needle with two plastic wings ◦ Through-the-needle: inserted through a hollow needle

 Inserting the IV catheter ◦ Keep the beveled side up. ◦ Maintain adequate traction. ◦ Use a constricting band above the site.  Remove the band while assembling IV equipment. Courtesy of Rhonda Beck

 Inserting the IV catheter (cont’d) ◦ Prep site. ◦ Apply lateral traction, while holding catheter bevel side up. ◦ Insert at a 45-degree angle. ◦ Push through the skin until the vein is pierced.

 Inserting the IV catheter (cont’d) ◦ Drop angle to 15 degrees and advance catheter a few centimeters. ◦ Slide sheath off needle into vein. ◦ Apply pressure to the vein. ◦ Remove needle. ◦ Dispose needle in sharps container

 Securing the line ◦ Tape the area to secure the catheter and tubing.  Double back the tubing to create a loop. ◦ Cover the site with sterile gauze and secure with tape.  See Skill Drill 11-2.

 Changing an IV bag ◦ Stop the flow by closing the roller clamp. ◦ Prepare the new IV bag. ◦ Remove the piercing spike, and insert it into the port on the new bag. ◦ Ensure the drip chamber is filled, and open the roller clamp.

 Discontinuing the IV line ◦ Shut off the flow. ◦ Peel tape back. ◦ Stabilize the catheter. ◦ Do not remove IV tubing from hub. ◦ Pull catheter and IV line from patient’s vein. ◦ Apply pressure.

 Saline locks ◦ Maintain active IV site without running fluids through vein ◦ Attached to end of IV catheter ◦ Filled with approximately 2 mL of saline ◦ Also called intermittent sites (INT)

 Catheters ◦ The best gauges for over-the-needle catheters are:  20-, 22-, 24-, 26- ◦ Butterfly catheters are ideal. Courtesy of Rhonda Beck

 IV locations ◦ Explain your actions to child and parent ◦ Hand veins remain the location of choice. ◦ Technique for starting pediatric IV line:  Use penlight to illuminate veins through back of hand ◦ Scalp vein cannulation can be difficult.

 Checks to perform after IV administration: ◦ Fluid ◦ Administration set ◦ Height of bag ◦ Catheter type ◦ Constricting band

 Infiltration: escape of fluid into surrounding tissue ◦ Causes area of edema ◦ Causes include:  Catheter passes through vein and out other side  Patient moves excessively  Tape becomes lose or dislodged  Catheter is inserted at too shallow an angle

 Infiltration (cont’d) ◦ If infiltration occurs:  Discontinue the IV line.  Reestablish IV line in the opposite extremity  Apply direct pressure over the area.  Do not wrap tape around extremity

 Occlusion: blockage of vein or catheter ◦ First sign: decreasing drip rate or blood in the IV tubing ◦ May develop due to:  Position of catheter within the vein  Patient’s blood pressure overcoming the flow ◦ If occlusion does not dislodge:  Discontinue.  Reestablish IV in opposite extremity

 Vein irritation ◦ Often caused by too-rapid infusion rate ◦ If redness at the IV site occurs:  Discontinue the IV line.  Save the equipment for analysis.  Reestablish the IV line in the other extremity with new equipment.

 Thrombophlebitis: inflammation of the vein ◦ May be caused by lapses in aseptic technique ◦ Pain and tenderness along the vein and redness and edema at the venipuncture site ◦ Appear several hours after IV therapy ◦ Stop the infusion and discontinue the IV at that site.

 Hematoma: accumulation of blood in the tissues surrounding an IV site ◦ Often caused by:  Vein perforation  Improper catheter removal ◦ Develops while inserting catheter: stop and apply direct pressure ◦ Develops after inserting catheter: evaluate the IV flow ◦ Develops as a result of discontinuing the IV: apply pressure Courtesy of Rhonda Beck

 Nerve, tendon, or ligament damage ◦ Results in sudden and severe shooting pain ◦ Remove catheter and select another IV site.  Arterial puncture ◦ Bright red blood will spurt through the catheter. ◦ Withdraw the catheter and apply direct pressure for at least 5 minutes.

 Allergic reactions ◦ Anaphylaxis must be treated aggressively. ◦ If an allergic reaction occurs:  Discontinue the line and remove the solution.  Leave the catheter in place.  Attach a saline lock.  Notify medical control.  Maintain an open airway; monitor vital signs.  Retain the solution or medication for evaluation.

 Circulatory overload ◦ Problems may occur in patients with cardiac, pulmonary, or renal dysfunction. ◦ To treat:  Slow the IV rate.  Raise the patient’s head.  Administer high-flow oxygen.  Monitor vital signs and breathing adequacy.

 Air embolus ◦ Avoid by properly flushing an IV line and replace empty IV bags with full ones ◦ To treat:  Place patient on left side with head down.  Administer 100% oxygen.  Transport to closest facility  Assist ventilations if needed.