Purpose is to provide necessary amounts and concentrations of water and electrolytes for normal cellular function
When should a patient be on continual IV maintenance fluid?
When unable to take daily fluid requirements orally or via GI tract (like through a G-tube)
Support kidney perfusion
When should a patient generally NOT be on continuous IV fluids?
When the patient is on full maintenance IV fluids (100% of daily fluid requirements) AND taking oral fluids
This typically occurs post-surgery
The patient was NPO & on IV fluid
The patient has the surgery and their diet is started
If patient is on full IV fluids PLUS taking PO fluids QUESTION THIS
Did you or someone else over look a "D/C IV Fluids order?"
Talk to MD
Can lead to fluid overload & heart failure
Typically...the MD writes: "D/C IV Fluids once pt. taking adequate PO fluids"
In peds: an typical order would be: IV+PO = 75ml/hr. (decrease IV rate as PO intake increases)
One-quarter normal saline (NS)
0.225% NS, very commmonly used
0.33% NS, uncommon
0.45% NS, very commonly used
0.9%, very commonly used
LR is a solution containing:
sodium, chloride, lactate, potassium, and calcium in water
Designed to very closely mirror the contents and concentrations of human blood
Often given after blood loss, burns, trauma, surgeries
What is the purpose of lactate in LR?
The lactate allows for a metabolic alkalizing effect (can raise pH overtime)
Lactate metabolized to CO2 & H2O in liver. This process requires H+ atoms to be used
If LR is used long term, can lead to a metabolic alkalosis
Some things to consider:
DO NOT use LR when giving blood
The calcium from LR & citrate of blood products will cause coagulation
Not all medications are compatible with LR
Ceftriaxone is on example. Can crystallize with LR
Does not contain enough potassium to raise low potassium blood levels
But, should be avoided if hyperkalemia present
Dextrose 5% (or 10%) in Water
When are dextrose in water solutions used?
Dehydration with adequate circulatory volume
May give D5W, or D5 0.45%NS, D5NS (depending on lab sodium levels)
Patient needs some amount of glucose
May be NPO, have low serum glucose evident in lab results
Sodium levels are adequate or high
Hypernatremia of various causes
D5 in water helps to dilute serum sodium concentration
Nephrologists tend to use maintenance or boluses to control sodium levels
Urine replacement of diabetes insipidus (body urinates high volumes of water)
When is D10 (or higher) solution used?
When blood glucose remains low
Usually D5W used first. But is serum glucose remains low, may increase to D10W
Pharmacy can prepare solutions with higher dextrose concentrations
When is dextrose 50% used?
Used in hypoglycemic patients (and mainly in adults)
In pediatrics, D10 pushes are typically given for hypoglycemia
This would not be a drip, but rather an IV push to rapidly increase blood glucose levels
how do iv fluids tend to affect blood ph?
Normal saline tends to make blood pH more acidic
Chloride ion may impair bicarbonate absorption in kidney-->leading to acidotic state
Lactated Ringers tends to make pH more alkalotic
Lactate metabolized by liver to bicarbonate, so pH may rise
how to bolus iv fluids
How fast do you give a bolus? (in practice and literature, you will find a range of answers) Is imminent death a possibility?
If yes, give bolus as quick as possible. Remember, hypotension can quickly lead to cardiac arrest
Ideally via a central line or large bore IV, "wide open," and "to gravity," and with use of "gravity tubing
Use pressure bags, rapid infurser systems, or manually squeeze in the fluid
No, give over approx. 30-60min (again, you will here different answers as to how fast to give a bolus in a non-critical patient). Your hospital may have a policy regarding boluses.
Use a pump for boluses for mild hypotension, low urine output, etc.
Can you give too much fluid?
Of course! As the nurse, it is your job to make sure that the patient is tolerating the extra fluid
Signs of not tolerating:
Respiratory distress, new congestion/crackle lung sounds
Loss of IV access, hematoma around IV site
Bolus administration options:
Bolus using the pump. Usually set at 999ml/hr (or ordered rate). But, if patient needs fluid ASAP, use a pressure bag or fluid infuser.
Bolus using a pressure bag. This may require checking pressure bag after a few minutes (after some fluid has infused) to make sure pressure is still adequate to squeeze in fluids.
Belmont rapid infuser. Can deliver 1L in <45 seconds. Pt. must weight >15kg
A dispensing pen is common in PEDS, since a bolus volume is typically much less than a full liter bag
Also, when possible, use:
Large bore/gravity tubing
Large volume rapid infuser catheters (RICs) (more on IV access here)
What happens when you "re-spike an iv fluid bag?"
1. Don't do it 2. Excessive air enters the bag 3. If you are using an IV pump, this should not be an issue. But, if using a gravity bag, it could lead to an air embolism Check out a related story of a patient death caused by bag re-spiking here!