Caring for Clients with Fluid,

Electrolyte, and Acid Base

Imbalances
 Homeostasis
• 50-60% of the human body is water (decreases with age)
• Body fluids are classified according to their location
• Intracellular – most water about 63 % is located here
– Extracellular (mainly responsible for transport of nutrients and wastes)
interstitial water, water in blood plasma, lymph 37%
– Transcellular fluid includes CSF, aqueous and vitreous humor, synovial fluid,
serous fluids in body cavities, glandular secretion

• Fluid compartments are separated by selectively permeable membranes

that control movement of water and solutes
• The process of homeostasis involves delivery of oxygen and nutrients to
the cells and removal of waste

• Most disease processes, tissue injuries and surgical procedures greatly

influence the physiologic status of fluids and electrolytes in the body.
 Homeostasis
• Functions of body water
• transport nutrients, e-lytes, and O2 to the cells
• excretion of wastes
• regulates body temp
• lubricates joints and membranes
• medium for food digestion

Daily body fluid intake and losses

• liquid 1000-1200ml urine 100-1400ml
• food 800-1000ml feces 100 ml
• oxidation 200-300ml lungs 400-500ml
skin 300-500ml

• Total – 2000-2500ml 1800-2500ml

 Fluid Loss
Loss
• “Sensible”
Can be seen.
Urine
Sweat
• “Insensible”
Not visible.
Skin (evaporation)
Lungs
Feces
 Body Fluids
• Water= most important nutrient for life.
• Loss of 10% body fluid = 8% weight loss
SERIOUS
• Loss of 20% body fluid = 15% weight loss
FATAL
• Fluid gained each day should = fluid lost each
day
(2 -3L/day average)
• What is the minimum output per hour
necessary to maintain renal function?
30ml/hr
 Variations in Body Fluids

• Elderly: Have lower % of total body fluid than

younger adults
• Women: Have lower % total body fluid than
men
• WHY DO YOU THINK THIS IS ?????
Muscle tissue has more H20 content THAN adipose tissue
Increased risk for fluid/electrolyte imbalance with
decreased muscle since muscle cells hold more water
 Calculating Fluid Intake
• 100 ml/kg for the first 10kg of weight plus
• 50 ml/kg for the next 10kg of weight plus
• 15 ml/kg per remaining kg of weight
 Movement of Body Fluids
• Osmosis
• Diffusion
• Filtration
• Active transport
 Transport of Water and Fluids
• Osmolality: concentration of a solution determined by the number of
dissolved particles per kilogram of water. Osmolality controls water
movement and distribution in body fluid compartments

• Diffusion: the random movement of particles in all directions through a

solution

• Active transport: movement of solutes across membranes; requires

expenditure of energy

• Filtration: transfer of water and solutes through a membrane from a

region of high pressure to a region of low pressure

• Osmosis: movement of water across a membrane from a less

concentrated solution to a more concentrated solution
27_table_01
 Fluid volume deficit FVD
(Hypovolemia)
• Causes include:
Increased output, Hemorrhage, vomiting,
diarrhea, burns,
OR
• Fluid shift out of vascular space ( “third
spacing” ) into interstitial spaces
 Assessment of Fluid Deficit
• Hypotension
• Weak rapid pulse
• Temperature decreased if hypovolemic, and
increased in dehydration
• Weight loss
• Skin turgor poor in dehydration and possible
edema in hypovolemic
• Concentrated urine and blood
 Assessment of Fluid Deficit
• Earliest sign is thirst
• Sunken eyes
• Dry mucous membranes
• Weak
• Sleepy
 Assessment
FVD - Hypovolemia
Cardiovascular:
• Diminished peripheral pulses; quality 1+(thready)
• Decreased BP & orthostatic hypotension
• Increased HR
• Flat neck & hand veins in dependent position
• Elevated Hematocrit (Hct)
Gastrointestinal:
• Thirst
• Decreased motility; diminished bowel sounds, possible
constipation
 Assessment
FVD – Hypovolemia (continued)
Integumentary:
Neuromuscular: • Dry mouth & skin
• Decreased CNS activity
• Poor turgor (tenting)
(lethargy to coma)
• Pitting edema
• Possible fever
• Sunken eyeballs
• Skeletal muscle weakness
• Hyperactive DTR
Renal: Respiratory:
• Decreased output • Increased rate and depth
• Increased spec grav of urine
• Weight loss
• Hypernatremia
 Nursing Diagnosis - FVD
• Deficient Fluid Volume

R/T loss of GI Fluids via vomiting

AEB elevated Hct, dry mucous membranes,
decreased output, thirst
 Planning - FVD

• Client will demonstrate fluid

balance aeb moist mucous
membranes, balanced I & O
measurements, Hct WNL, by ….
 Interventions for
FVD - Hypovolemia
• Prevent further fluid loss
• Oral rehydration therapy
• IV therapy
• Medications; antiemetics, antidiarrheals
• Monitor CV, Resp, Renal, GI status
• Monitor electrolytes – possible supplement rx
• MONITOR WEIGHT and I & O
 Treatment of Deficit
• Correct cause
• IV fluids
• I and O
• Skin care
• Assist with ADL’s
 Fluid Volume Excess
FVE - Hypervolemia
• Fluid overload is an excess of body fluid -
overhydration
• Excess fluid volume in the intravascular area-
hypervolemia
• Excess fluid volume in interstitial spaces edema
• Third spacing could be in the abd- ascites
• pleural effusion in the lungs
 Fluid Volume Excess
• Causes:
• Increased Na/H2O retention
• Excessive intake of Na (PO or IV)
• Excessive intake of H2O ( PO or IV)
(Water intoxication)
• Syndrome of inappropriate antidiuretic
hormone (SIADH)
• Renal failure, congestive heart failure
 Assessment Findings
• Can lead to circulatory overload
• Increases bp
• Heart increases its force of contraction
• Pitting edema
• Weight gain
• Increased breathing effort
• Jugular vein distention
• Moist lung sounds
FLUID VOLUME EXCESS/ Treatment
– Correct cause
– Restrict H2O and Na
– Diuretics
– Digitalis
– Possible dialysis
– IV fluids with E-lytes
FLUID VOLUME EXCESS/ Treatment
– Monitor for excess excretion of H2O R/T diuretics
– Maintain fluid restriction
– Consult dietary for salt restrictions
– Watch for skin problems
– HOB ^ 30 degrees
 Third Spacing
• Translocation of fluid from the intravascular or
intercellular space to tissue compartments
• Becomes trapped and useless
• Associated with loss of colloids
– Hypoalbuminemia
– Burns
– Serve allergic reactions
 Assessment Findings
• Hypovolemia without weight loss
• Hypotension
• Shock
• Circulatory failure
• Enlargement of localized organ cavities
• Generalized edema- ANASARCA
 Medical Management
• IV fluids
• Blood products such as albumin
• RESTORE COLLOID ONCOTIC pressure
 Nursing Management
• LOOK FOR HYPERVOLEMIA
 Assessment
FVE - Hypervolemia
CV: GI:
Elevated pulse; 4+ bounding, Increased motility
elevated BP, distended neck & Stomach cramps
hand veins, ventricular gallop Nausea & Vomiting
(S3)
Hyponatremia Renal:
Weight gain
Resp: Decreased spec grav of
Dyspnea, Moist Crackles, urine
Tachypnea
Neuromuscular:
Integumentary: Altered LOC, headache,
Periorbital edema skeletal muscle twitching
Pitting or Non-pitting edema
 Nursing Diagnosis - FVE
Fluid volume excess

R/T excessive H20 intake

AEB confusion, headache, muscle twitching,

abdominal cramps, elevated BP and HR,
hyponatremia.
 Planning - FVE
• Client will demonstrate fluid balance by
balanced I & O measurements, Serum Na
WNL, etc. by ….
 Interventions
FVE - Hypervolemia
• Restore normal fluid balance, prevent
further overload
• Drug therapy; diuretics
• Diet therapy; decrease Na & fluids
• Monitor intake and output (I & O)
• Monitor weights
• Monitor electrolytes
• Monitor CV, Resp, Renal systems
 Interventions
FVE - Hypervolemia
• Drug therapy- - diuretics for overhydration
increases excretion of water and sodium
• Diet-- restricting fluid and sodium intake
• Monitor lab work
 IV Therapy
• Parenteral administration of fluids and
additives into a vein
– Restore hydration
– Replace electrolytes
– Administer vitamins
– Provide nutrients
– Administer drugs
– Replace blood and blood products
 Osmolarity
• Concentration of particles in solution
• The greater the concentration (Osmolarity) of a
solution, the greater the pulling force (Osmotic
pressure)
• Normal serum (blood) osmolarity = 280-295 mOSM/kg
• A solution that has HIGH osmolarity is one that is >
serum osmolarity = HYPERTONIC solution
• A solution that has LOW osmolarity is one that is <
serum osmolarity = HYPOTONIC solution
• A solution that has equal osmolarity as serum =
ISOTONIC solution
 Crystalloid Solutions
• Consist of water and uniformly dissolved
crystals such as salt or sugar
• Isotonic , hypotonic, hypertonic
 Saline Solutions
(1) 0.9% Normal Saline – Think of it as ‘Salt and water’
• Principal fluid used for intravascular resuscitation and
replacement of salt loss e.g diarrhea and vomiting
• Distribution: Stays almost entirely in the Extracellular
space

(2) 0.45% Normal saline = ‘Half’ Normal Saline =

HYPOtonic saline
• severe dehydration
• Leads to HYPOnatraemia if plasma sodium is normal
• May cause rapid reduction in serum sodium if used in
excess or infused too rapidly. This may lead to cerebral
edema
 Dextrose solutions
(1) 5% Dextrose (often written D5W) – Think of it as ‘Sugar
and Water’
• Primarily used to maintain water balance in patients
who are not able to take anything by mouth
• Provides some calories [ approximately 10% of daily
requirements]
• Regarded as ‘electrolyte free’ – contains NO Sodium,
Potassium, Chloride or Calcium

(2) Dextrose saline – Think of it as ‘a bit of salt and sugar’

• Similar indications to 5% dextrose; Provides Na+
30mmol/l and Cl- 30mmol/l Primarily used to replace
water losses post-operatively
• Advantage – doesn’t commonly cause water or salt
overload.
 Isotonic solutions
• Contain the same concentration of dissolved
substances as in plasma
• Maintain fluid
• Causes no redistribution of body fluid
 Isotonic Fluid
• Isotonic fluids have the same
concentration of particles (osmolality) as
ICF (275-295 mOsm/L)
• Osmotic pressure is therefore the same
inside & outside the cells
• Cells neither shrink nor swell in an
isotonic solution, they stay the same
 Isotonic Fluid
• Expands both intracellular and
extracellular volume
• Used commonly for: excessive
vomiting,diarrhea
• 0.9% Normal saline
• D5W
• Ringer’s Lactate
 Hypotonic Solutions
• Fewer dissolved substances than plasma
• Rehydrating pts experiencing fluid deficit
• Since it is dilute water passes through
membrane of blood cells causing them to
swell causing increase in bp
• Passes through capillary walls into cells and
interstitial spaces
 Hypotonic Fluids
• Hypotonic fluids have less
concentration of particles (low
osmolality) than ICF
• This low osmotic pressure shifts fluid
from ECF into cells
• Cells placed in a hypotonic solution
will swell
 Hypotonic Fluids
• Used to “dilute” plasma particularly in
hypernatremia
• Treats cellular dehydration
• Do not use for pts with increased ICP risk
or third spacing risk
• 0.45%NS
• 0.33%NS
 Hypertonic Solutions
• More dissolved substances than plasma
• Draws fluid into the intravascular
compartment from cells and interstitial spaces
• expand circulatory volume
 Hypertonic Fluids
• Hypertonic fluids have a higher
concentration of particles (high
osmolality) than ICF
• This higher osmotic pressure shifts
fluid from the cells into the ECF
• Therefore Cells placed in a hypertonic
solution will shrink
 Hypertonic Fluids
• Used to temporarily treat hypovolemia
• Used to expand vascular volume
• Fosters normal BP and good urinary output
(often used post operatively)
• Monitor for hypervolemia !
Not used for renal or cardiac disease.
D5% 0.45% NS
• D5% NS
• D5% LR
 NCLEX Practice
Intravenous fluids are ordered for your client
who is experiencing diarrhea and vomiting for
the past 2 days. Which IV solution would the
nurse expect to see prescribed?
a. D5NS
b. 0.45%NS
c. D51/2NS
d. RL
 Hmmm…….

• What type of IV fluid

(hypotonic – isotonic – hypertonic)
might be of benefit to this client with low
albumin levels?
 Clinical Application
You have been assigned to care for an 80y.o. client
admitted with hypernatremia that has an IV infusing
0.45% NS @ 100ml/hr via pump and an indwelling
urinary catheter. At 11am you assess an output in the
urinary drainage bag of 150ml dk amber urine. You
also notice that the client is SOB while speaking on the
phone to her daughter.
What do you think is happening??
What will you do??
 Consider this….
• When tissue injury occurs, proteins
pathologically leak from the intravascular
space into the intersititial space.
Termed: Third spacing
• This explains __________
 Colloid solutions

• The colloid solutions contain particles which do not readily

cross semi-permeable membranes such as the capillary
membrane
• Thus the volume infused stays (initially) almost entirely
within the intravascular space
• Replace circulating blood volume
• Pull fluid from compartments into the intravascular space
• Blood, blood products, plasma expanders
 Electrolytes

• Work with fluids to keep the body healthy and in

balance
• They are solutes that are found in various
concentrations and measured in terms of
milliequivalent (mEq) units
• Can be negatively charged (anions) or positively
charged (cations)
• For homeostasis body needs:
Total body ANIONS = Total body CATIONS
 Electrolytes
Cations Anions
Positively charged Negatively
charged
 Sodium Na+
 Potassium K+ • Chloride Cl-
 Calcium Ca++ • Phosphate PO4-
 Magnesium • Bicarbonate
Mg++ HCO3-
 Diagram of Serum
Electrolyte Results
Figure 52-15 A, Format
for a diagram of serum
electrolyte results. B,
Example that may be
seen in a primary care
provider’s
documentation notes.
 Electrolyte Functions
• Regulate water distribution
• Muscle contraction
• Nerve impulse transmission
• Blood clotting
• Regulate enzyme reactions (ATP)
• Regulate acid-base balance
 Sodium Na+
• 135-145mEq/L
• Major Cation
• Chief electrolyte of the ECF
• Regulates volume of body fluids
• Needed for nerve impulse & muscle
fiber transmission (Na/K pump)
 Hmmm…

Hyper and Hypo Natremia are the most

common electrolyte disturbances. Why do
you think that is?

It is most abundant in the EXTRACELLULAR

FLUID and therefore more prone to
fluctuation.
 Sodium
(135 to 145 mEq/L)

• Sodium level is vital for skeletal muscle

contraction, cardiac contraction, nerve
impulse transmission, and normal osmolality
and volume of the ECF.
 Hypernatremia
• Serum Na+> 145mEq/L
• Excess Na in blood
• Elderly persons following surgery or fever
• Prolonged diuretic therapy
• Uncontrolled diabetic
• Profuse watery diarrhea
• Excessive salt intake without sufficient water intake
• Severe burns
 Hypernatremia
• Thirst
• Dry, sticky mucous membranes
• Decreased urine output
• Fever
• Rough, dry tongue
• Lethargy
• Can progress to coma
 Hypernatremia
• Treatment
– Oral administration of plain water
– IV administration of a hyotonic solution such as
.45% Na or 5% Dextrose
– Pt. Teaching avoid high Na foods, canned soups,
processed foods, ketchup AVOID antacids high in
sodium bicarb
 Hypernatremia Interventions
• Priorities for nursing care of the patient with
hypernatremia include monitoring the
patient's response to therapy and preventing
hyponatremia and dehydration.
• Drug therapy.
• Nutrition therapy.
 Let’s think about….
Hypernatremia
• What are some medical conditions that may cause elevated serum
Na?
Renal failure
Diabetes Insipidus
Diabetes Mellitus ( hyperglycemic dehydration)
Cushings syndrome (hyperaldosteronism)
• What are some other patient populations at risk for
hypernatremia?
Elderly ( decreased thirst mechanism )
Patient’s receiving:
-tube feedings
-corticosteroid drugs
-certain diuretic therapies
• Seizures, coma, death my result if hypernatremia is left untreated.
Why?
Cells loose fluid into the ECF causing irreversible cell damage.
 Hyponatremia
• Low sodium in blood
• Excess water in the blood
• CHF
• Profuse diaphoresis
• Excessive ingestion of plain water
• Administration of nonelectrolyte IV fluids
• Profuse diuresis
• Loss of GI secretions from vomiting, suctioning, draining
fistulas
• Addison’s disease
 Hyponatremia
Symptoms
• Anorexia • Bradycardia
• Headache • Hypertension or hypotension
• Nausea • Altered temperature regulation
• Emesis • Dilated pupils
• Impaired response to verbal stimuli • Seizure activity
• Impaired response to painful stimuli • Respiratory arrest
• Bizarre behavior • Coma
• Hallucinations • Hypotension
• Obtundation • Renal failure as consequence of
• Incontinence hypotension
• Respiratory insufficiency • Tachycardia
• Decorticate or decerebrate posturing • Weakness
• Muscular cramps
 Hyponatremia
• Treatment
– Oral administration of sodium
– Administration of IV solution containing Na
 Hyponatremia Interventions
• The priority for nursing care of the patient
with hyponatremia is monitoring the patient’s
response to therapy and preventing
hypernatremia and fluid overload.
• Drug therapy.
• Nutrition therapy.
 Nursing Management
• Early detection
• Accurate intake and output
• Vital signs 1-4 hours
• Monitor labs
• Administer IV solutions/meds
• Prescribed dietary restrictions
 Lets think about …
Hyponatremia
• What are some medical conditions that may cause a
dilutional hyponatremia?
CHF
Renal Failure
SIADH ( Cancer, pituitary trauma )
Addisons Disease ( hypoaldosteronism & Na loss )
• What are some conditions that might cause actual loss
of sodium from the body?
GI losses – nasogastric suctioning, vomiting, diarrhea
Certain diuretic therapies
• Permanent neurological damage can occur when serum
Na levels fall below 110 mEq/L. Why?
Hypotonic environment swells cells, increasing ICP –
brain damage
 Critical Thinking
Hypo / Hyper Natremia

For the client experiencing For the client experiencing

FVE & hyponatremia d/t FVD and hypernatremia
excessive intake of water, d/t excessive water loss,
which IV solution would you which IV solution would
expect the physician to you expect the physician
order? to order?
a. D5NS a. D5 ½ NS
b. NS b. D5RL
c. D5W c. D5W
d. ½ NS d. ½ NS
 Potassium K+
• Potassium is the most abundant cationic (positively charged)
electrolyte inside cells
• Potassium is obtained from a variety of foods, the most
common being fruit and juices, vegetables, fish and meats.
• It has been estimated that for normal body functions to be
maintained, a person must consume 5-10 mEq of K per day
• The average diet usually provides 35-100 mEq of K a day
• Excess dietary K is usually excreted by the kidneys in urine.
 Potassium K+
• Normal K levels is 3.5-5.0 mEq/L
• Aids in muscle contraction, nerve & electrical
impulse conduction, regulates enzyme activity,
regulates IC H20 content, assists in acid-base
balance
• Regulated by kidneys/ hormones
• Inversely proportional to Na
 Potassium (3.5 to 5.0 mEq/L)
• Depolarization and generation of action
potentials, as well as regulating protein
synthesis and glucose use and storage
POTASSIUM
 Hyperkalemia
• Elevated K levels
• Kidney disease
• Burns
• Potassium sparing diuretics
• Overuse of K supplements
• Salt substitutes
• Crushing injuries
• Addison’s disease
• Rapid administration of parenteral potassium salts
 Hyperkalemia
• Diarrhea
• Nausea
• Muscle weakness
• Paresthesias
• Cardiac dysrhythmias
• A Twave shown on EKG waveform
 Hyperkalemia
• Treatment
– Depends on the cause and severity
– Decrease intake of potassium
– Intravenous glucose and insulin
– Dialysis
– Kaexalate
 Lets think about …
Hyperkalemia
• What are some medical conditions that may cause hyperkalemia?
Renal Disease=most common cause
Burns and other major tissue trauma
Metabolic Acidosis
Addison’s Disease ( Na loss leads to K retention )
• What are some conditions that might cause potassium levels to rise
in the body?
Certain diuretic therapies
Excessive intake – ( inappropriate supplements)
• Cardiac arrest may occur when serum K levels rise above mEq/L.
Why?
Decreased electrical impulse conduction leads to bradycardia and
eventual asystole.
 Hypokalemia
• Diuretics
• Vomiting
• Diarrhea
• NG tube
• Large doses of corticosteroids
• IV administration of insulin and glucose
• Prolonged administration of nonelectrolyte
parenteral fluids
 Hypokalemia
• Muscle fatigue
• Leg cramps
• Abdominal distention
• Cardiac dysrhythmias
• U wave on EKG
• Paresthesias
• Hypotension
• Flaccid paralysis
 Hypokalemia
• Treatment
– Eliminate the cause
– Exchange of type of diuretics
– Increase intake of potassium
– K-Lor, K-Lyte, Klorvess
 Nursing Management
• IV potassium must be administered diluted in
an IV solution and administered at a rate
below 10 mEq/hour
 Lets think about …
Hypokalemia
• What are some medical conditions that may cause a hypokalemia?
Renal Disease / CHF (dilutional)
Metabolic Alkalosis
Cushings Disease ( Na retention leads to K loss )
• What are some conditions that might cause actual loss of potassium
from the body?
GI losses – nasogastric suctioning, vomiting, diarrhea
Certain diuretic therapies
Inadequate intake – ( body cannot conserve K, need PO intake)
• Cardiac arrest may occur when serum K levels fall below 2.5 mEq/L.
Why?
Increased cardiac muscle irritability leads to PACs and PVCs, then AF
 Calcium Ca++
• Normal levels 8.8-10 mg/dl
• Most abundant in body but:
99% in teeth and bones
• Needed for nerve transmission, vitamin B12
absorption, muscle contraction & blood clotting
• Inverse relationship with Phosphorus
• Vitamin D needed for Ca absorption
• Blood clotting
• Parathyroid hormone regulates levels
 Hypocalcemia
• Vitamin D deficiency
• Hypoparathyroidism
• Severe burns
• Acute pancreatitis
• Drugs such as corticosteroids
• Rapid administration of multiple units of
blood that contain an anticalcium additive
• Intestinal malabsorption disorders
 Hypocalcemia
• Tingling in the extremities and area around
the mouth (circumoral paresthesia)
• Muscle and abdominal cramps
• Carpodedal sapsms
– Trousseu’s sign
• Place a BP cuff on the upper arm, inflate it between the
systolic and diastolic BP and wait three minutes
• The nurse observes the client for spasms of the hand
which is evidenced by the hand flexing inward
 Hypocalcemia
• Chvostek’s sign
– If the nurse taps the client’s facial nerve which lies under
the tissue in front of the ear, the client’s mouth twitches
and the jaw tightens
• Mental changes
• Seizures
• bleeding
• Cardiac dysrhythmias
• Laryngeal spasms with airway obstruction
• Tetany
Chovstek Trousseau
 Hypocalcemia
• Treatment
– Oral calcium and vitamin D
– IV administration of calcium salts such as calcium
gluconate
 Lets think about …
Hypocalcemia
• What are some medical conditions that may cause hypocalcemia?
Hypoparathyroidism (low PTH levels = decreased release of Ca from
bones)
S/P thryoid surgery ( low Calcitonin = decreased release of Ca from
bones) Acute pancreatitis
Crohns Disease
Hyperphosphatemia ( ESRF)
• What are some other conditions that might cause low Ca?
GI losses – nasogastric suctioning, vomiting, diarrhea
Long term immobilization
Lactose intolerance
• If hypocalcemia is prolonged, the body will utilize stored Ca from
bones.
What complication might arise?
Fractures ( late sign )
 Hypercalcemia
• Parathyroid gland tumors
• Multiple fractures
• Paget’s disease
• Hyperparathyroidism
• Excessive doses of vitamin D
• Prolonged immobilization
• Some chemo
• Some malignant disorders
 Hypercalcemia
• Deep bone pain
• Constipation
• Anorexia
• N,v
• Polyuria
• Thirst
• Pathologic fractures
• Mental changes such as decreased memory and attention
span
• Kidney stones
 Hypercalcemia
• Increase oral fluid intake and limit calcium
consumption
• IV .45% or 0.9% NSS and a diuretic to help
increase calcium excretion in the urine
• Oral phosphates or Calcitonin (Cibacalcin)
• Plicamycin (mithracin)
 Lets think about …
Hypercalcemia
• What are some medical conditions that may cause hypercalcemia?
Hyperparathyroidism (high PTH levels = increased release of Ca from
bones)
Paget’s Disease
Some Cancers – Multiple Myleoma
Chronic Alcoholism ( with low serum phosphorus )

• What are some other conditions that might cause low Ca?
Excessive intake of Ca OR Vitamin D
Excessive intake of OTC antacids

If hypercalcemia is uncorrected, AV block and cardiac arrest may

occur.
 Magnesium
• Next to K most abundant cation in the intracellular fluid
• Found in bone cells and specialized cells of the heart, liver and
skeletal muscles
• Involved in the transmission of nerve impulses and muscle
excitability
• Activates several enzymes inc. functioning of B vitamins
• Normal level 1.3-2.1 mEq/L
 Hypomagnesemia

• Serum < 1.3mEq/L

• Results from decreased intake, prolonged NPO
status, chronic alcoholism & nasogastric suctioning
• S/S: muscle weakness, cardiac changes, mental
changes, hyperactive reflexes & other hypocalcemia
S/S.
• Tx: replacement IV therapy
restore normal Ca levels ( Mg mimics Ca)
seizure precautions
 Hypomagnesemia

• Common in critically ill patients

• Associated with high mortality rates
• Increases cardiac irritability and ventricular
dysrhythmias - especially in patients with recent MI
• Maintenance of adequate serum Mg has been shown
to reduce mortality rates post MI
 Hypomagnesemia
• by use of diuretics
• Chronic alcoholism
• Preeclampsic
• Diabetic ketoacidosis
• Severe renal disease
• Severe burns
• Severe malnutrition
• Hyperaldosteronism
• Intestinal malapsorption
• Prolonged gastric suction
 Hypomagnesemia
• Tachycardia
• Cardiac dysrhythmias
• Neuromuscular irritability
• Parathesias
• Leg and foot cramps
• HTN
• Mental changes
• Positive Chvostek’s and Trousseau’s sign
• Dysphagia
• Seizures
 Hypomagnesemia
• Treatment
– Administration of oral mag
– Addition of mag rich foods
– Iv mag sulfate
 Hypermagnesium
• Kidney disease
• Over use of otc drugs with magnesium
containing antacids
• Addison’s disease
 Hypermagnesium
• Flushing
• Warmth
• Hypotension
• Lethargy
• Drowsiness
• Bradycardia
• Muscle weakness
• depressed respers
• coma
 Hypermagnesium
• Hemodialysis may be necessary
• May need mechanical vent if severe resp.
distress
 Nursing Care
• Calcium gluconate is antidote for mag sulfate
 Chloride Cl-
• 95-105mEq/L
• Most abundant anion in ECF
• Combines with Na to form salts
• Maintains water balance, acid-base balance, aids in
digestion (hydrochoric acid) & osmotic pressure (with
Na and H20)
• Regulated by kidneys
• Follows Sodium (Na)
• Hyperchlormeia causes a state of acidosis
 Hypochloremia
• Serum level 96mEq/L
• Results from prolonged vomiting & suctioning
• S/S metabolic alkalosis, nerve excitability,
muscle cramps, twitching, hypoventilation,
decreased BP if severe
• Tx: diet/IV therapy
 Hyperchloremia
• Serum level > 106mEq/L
• Results from excessive intake or retention by
kidneys – metabolic acidosis
• S/S Arrhythmias, decreased cardiac output,
muscle weakness, LOC changes, Kussmauls’s
respirations
• Tx: restore fluid & electrolyte balance
 Phosphate PO4-
• 2.5-4.5mg/dl
• Needed for acid-base balance,neurological &
muscle function, energy transfer ATP & affects
metabolism of carbs/proteins/lipids, B vitamin
synthesis
• Found in the bones
• Regulated by intake and kidneys
• Inversely proportional to Calcium
Therefore some regulation by PTH as well
 Hypophosphatemia
• Serum level < 1.8mEq/L
• Results from decreased intestinal
absorption and increased excretion
• S/S bone & muscle pain, mental
changes, chest pain, resp. failure
• Tx: Diet/ IV therapy
 Hyperphosphatemia
• Serum level> 2.6mEq/L
• Results from renal failure, low intake of calcium
• S/S: neuromuscular changes (tetany), EKG changes,
parathesia-fingertips/mouth
• Tx: Diet; hypocalcemic interventions
Medications: phosphate binding
• The body can tolerate hyperphosphatemia fairly well
BUT the accompanying hypocalcemia is a larger
problem!
 Bicarbonate
• Anion
• Acid base balance
• Removes excess acid from the body
• Transports CO2
 Critical Thinking - NCLEX
• The nurse is caring for a client with renal
failure whose magnesium level is 3.6 mg/dL.
Which of the following signs would the nurse
most likely expect to note in the client based
on this Mg level?
a. Twitching
b. Hyperactive reflexes
c. Irritability
d. Loss of deep tendon reflexes
 Electrolyte homeostasis
• This means to maintain balance… to
control by balancing the dietary intake of
electrolytes with the renal excretion and
reabsorption of electrolytes
 Interventions for F/E balance

• Assess patient carefully- note changes

• Monitor I & O (Intake & Output)
• Monitor weight changes
• Monitor urine
• Monitor vs
• Monitor lab results and dx test
• Maintain proper IV therapy
 Summary

• Fluid compartments in the body must

balance
• Body systems regulate F&E balance
• Assessment of body fluid is important to
determine causes of imbalance
• Interventions for imbalances are based on
the cause
 Case study
• An 85 year old retired teacher, seemed confused when his
duaghter came home from work. When she brings him to the
ER, his BP is 90//62mm Hg, his HR is 114 bmin, and his skin is
dry but cool. His daughter says that he seems “much weaker’
than usual, and he is unable to answer questions clearly. His
daughter reports that he has “lost his appetite” lately and has
not taken in much food or drink. The nurse starts an IV
infusion of 0.9% sodium chloride infusion at 100ml/hr.
 Case Study
• 1. What do you believe to be the main medical
problem at this time?
• The emergency department is very busy at
this time and when the nurse returns to assess
the client she is shocked that the entire 500
ml of saline has infused in under an hour.
• 2. What will the nurse do first? Then what
should she monitor for?
 Case Study
• 1. hypovolemia
• 2. The first action by the nurse would be to stop the infusion
and assess the patient’s vital signs immediately. In addition,
the nurse needs to monitor the patient for signs of fluid
overload. An incident report will need to be completed to
document the occurrence and an investigation performed of
how the IV infused so quickly.
 ACID/BASE Balance
• Acid base balance is important to normal bodily functions and
is regulated by the respiratory system and the kidney.
• An acid is a substance that can donate or release hydrogen
ions such as carbonic acid or hydrochloric acid.
• A base is a substance that can accept hydrogen ions, such as
bicarbonate.
• The pH is a measure of the degree of acidosis and alkalinity
and is inversely related to hydrogen ion concentration.
 ACID/BASE Balance
• When hydrogen ion concentration increases, the pH
decreases and leads to acidity.
• As hydrogen ion concentration decreases, the pH increases,
leading to more alkalinity.
• With the normal pH ranging from 7.35 to 7.45, acidosis occurs
when there is an excess of hydrogen or carbon dioxide (CO2)
and the pH falls below 7.35.
• Alkalosis occurs when there is a hydrogen or CO2 deficit and
the pH rises above 7.45.
Copyright 2008 by Pearson
Education, Inc.
 Acid - Base Balance
• Blood - normal pH of 7.2 – 7.45
• < 7.2 = acidosis > 7.45 = alkalosis
• 3 buffer systems to maintain normal blood
pH
1. Buffers
2. Removal of CO2 by lungs
3. Removal of H+ ions by kidneys
 Buffer
• Chemical substance that prevents large
changes in pH
• Buffer pair
– Taker – H+ increases the taker removes H+ from
the blood
– Giver- H+ decreases the giver donates H+ to the
blood
 Lungs
• Decreasing resp. rate
– Retains CO2
– Binds with water to form H+
– Increases H+ causing pH to decrease
– Respiratory acidosis
– OR -
• Increase resp. rate
– Blows off C02
– Decrease in H+
– Increase in pH
– Respiratory alkalosis
 Lungs
• Medulla oblongata senses changes in H+
• As plasma H+ increases the respiratory center
is stimulated then increases the rate and
depth of breathing increasing the excretion of
C02
• As plasma H+ decreases the medulla send
signals to decrease the rate of breathing
excreting CO2 by the lungs decreasing pH
 Kidneys
• Reabsorb and excrete H+
• Help to regulate bicarbonate
• Pts w/ kidney failure are usually acidotic
 Acidosis
• Below 7.35
• Death can occur if plasma pH is outside the
range of 6.8-8.7
Copyright 2008 by Pearson
Education, Inc.
 Respiratory Acidosis
– Any condition that decreases the effectiveness of the
respiratory system or causes prolonged hypoventilation
– Emphysema
– High doses narcotics
– Injury to the medulla
– Abdominal surgery
– Increased plasma levels of C02=forms H+=decreases
ph=acidosis
 Respiratory Acidosis
• Deep, rapid breathing
• Anorexia
• N,v
• Headache
• Confusion
• Flushing
• Lethargy
• Malaise
• Drowsiness
• Abdominal pain
• Weakness
• Cardiac dysrhythmias
• Stupor and coma
 Acidosis
• Metabolic acidosis
– Kidneys unable to excrete H+
– Uncontrolled Dm produces excess ketoacids that
overwhelm the buffer system
Copyright 2008 by Pearson
Education, Inc.
 Metabolic acidosis
• Caused by an increase in H+ production
• The classic metabolic causeof acidosis is
diabetes. Patients who do not produce (or
take) sufficient insulin to efficiently transport
glucose into cells must rely on other, less
efficient, methods of energy production. Acids
are byproducts of this inefficient metabolism
and cause metabolic acidosis.
 Metabolic acidosis
• The body attempts to compensate for this with the respiratory system in a
classic pattern known as Kussmaul’s Breathing, which is a pattern of deep
and rapid respirations. This pattern increases expiration of CO2 and
therefore decreases acidosis (increasing pH).
• Because it is not able to enter cells in sufficient quantity, glucose
accumulates in the bloodstream. As glucose levels continually rise, the
kidneys’ ability to reabsorb glucose is overwhelmed. Glucose “spills over”
into urine and, through osmosis, pulls water with it. This results in
dehydration that causes most of the manifestations of diabetic
ketoacidosis (DKA).
• Signs and symptoms of DKA include a gradual onset, warm and dry skin
with possible ‘tenting” (a sign of dehydration), Kussmaul’s breathing and
• excessive thirst, urination and hunger. Treatment is aimed at rehydration
and replacement of insulin.
 Metabolic acidosis
• Other causes of metabolic acidosis include
salicylate overdose. Aspirin (acetylsalicylic
acid, or ASA) is the most common source of
salicylate and can reach toxic levels in adults
with as little as 10 gm.5
• Treatment for metabolic acidosis is primarily
accomplished through increased ventilation.
 Acidosis
• Metabolic acidosis correction
– Buffer system removes some of the excess H+
– Respiratory system helps remove excess H+
• Hyperventilation or Kussmaul respirations
– Hyperventilation=decreased plasma C02=
decreased H+= increased pH
 Metabolic Acidosis
• Results from changes in HCO3- concentration
– Metabolic acidosis – abnormally low HCO3- in
systemic arterial blood
• Loss of HCO3- from severe diarrhea or renal dysfunction
• Accumulation of an acid
• Failure of kidneys to excrete H+
• Hyperventilation can help
• Administer IV sodium bicarbonate and correct cause of
acidosis
 Anion Gap
• Used to identify metabolic acidosis
• Difference betw. Sodium and potassium
canion concentrations and the sum of
chloride and bicarbonate anions in the
extracellular fluid
• Cations usually exceed the anions , the gap
reflects the remaining unmeasured anions
such as phosphates, sulfates, organic acids
and proteins
 Anion Gap
• Normal anion gap is 12 + or – 4 mEq/L
• Anion gap that exceeds 16 mEq/L indicates
but is NOT absolute diagnosis for metabolic
acidosis
• Low or negative anion gaps are rare
 Respiratory Acidosis
• Excessive carbonic acid
• Pneumothorax
• Hemothorax
• Pulmonary edema
• Acute bronchial asthma
• Atelectasis
• Pneumonia
• Some drug overdoses
• Head injuries
 Respiratory Acidosis
• Resp. insufficiency
• Lung sounds may be moist or absent
• Tachycardia
• Dysrhthmias
• Cyanosis
• Confusion
• Flushed skin
• Headache
• Weakness
• Stupor
• coma
 Acidosis
• Correction
– Kidneys excrete excess H+
– Resp. system can’t aid with correction since it is
dysfunctional
 Respiratory acidosis
• Caused by decreased elimination of CO2
secondary to either decreased respiration or
inadequate gas exchange. Narcotic coma,
cardiac arrest and COPD are examples of
conditions that cause respiratory acidosis.
Acidosis occurs due to a build up of CO2 that
causes an subsequent increase in H+
concentration and a decrease in pH.
 Respiratory Acidosis
• Treatment
– Mechanical ventilation
– IV sodium bicarb
Copyright 2008 by Pearson
Education, Inc.
 Alkalosis
• Increase in pH > 7.45
• Accumulation of base bicarbonate or decreased hydrogen
ions
• Excessive oral or parenteral use of bicarbonate containing
drugs or alkaline salts
• Rapid decreases in extracellular fluid volume (diuretic
therapy)
• Loss of hydrogen and chloride ions (vomiting, prolonged
gastric suctioning, hypokalemia, hyperaldosteronism)
 Metabolic Alkolosis
• Anorexia
• N,v
• Circumoral paresthseias
• Carpopedal spasm
• Hypertonic reflexes
• Tetany
• Decreased resper rate
 Metabolic alkalosis
• Caused by a decrease in H+ production, an
excess elimination of H+ or an increase of the
bicarbonate buffer.
• Excessive or prolonged vomiting or excessive
diuresis (for example, through inappropriate
use of medications such as Furosemide)
carries H+ with it, increasing pH and
decreasing acidity.
 Metabolic Alkolosis
• Treatment
– Eliminate cause
– Potassium salt if hypokalemia
– Sodium chloride to correct volume depletion
when extracellular fluid volume has decreased
Copyright 2008 by Pearson
Education, Inc.
 Alkalosis
• Respiratory alkalosis
– Any condition that causes hyperventilation
– Decreased plasma C02
– Anxiety
– ASA poisoning
– High fever
– Overactive thyroid
– Hypoxemia
– Mechanical ventilation
Copyright 2008 by Pearson
Education, Inc.
 Respiratory alkalosis
• Increased resp. rate
• Lightheadedness
• Numbness and tingling of fingers and toes
• Circumoral paresthesias
• Sweating
• Panic
• Dry mouth
• convulsions
 Respiratory alkalosis
• Caused by an increased elimination of CO2
through hyperventilation. This frequently
happens during an anxiety or ‘panic’ attack’.
• Respiratory alkalosis may also occur as a result
of “overcompensation” by overzealous
rescuers hyperventilating at 30-40 breaths per
minute for conditions resulting in respiratory
acidosis.
Copyright 2008 by Pearson
Education, Inc.
 Respiratory alkalosis

• Treatment
– Breath into a bag held over nose and mouth
– Sedation
 Acid-base Disturbances
• Rarely the primary cause of an illness, rather
they are a manifestation of an underlying
disease. Therefore, the primary treatment for
these disturbances is aimed at correcting the
underlying condition.
• Secondary treatment should be geared
towards stabilizing the patient to allow their
natural compensatory mechanisms to take
effect.
 Compensatory Mechanisms
• Compensation is the body’s way of restoring a
normal blood pH

• Remember: Acid + Base  Neutrality

• Compensation DOES NOT treat the root of the

problem – the reason for the acid-base
imbalance is STILL THERE!!!
 Compensatory Mechanisms
• The body has three means to try to
compensate for an acid-base imbalance

– Chemical

– Respiratory

– Renal
 Chemical Compensation
• Chemicals within the blood act within seconds
to correct respiratory or metabolic imbalances
• Used up quickly – not effective long-term
• Chemical buffers in the blood include
– Bicarbonate
– Phosphate
– Proteins
 Respiratory Compensation
• Used to compensate for metabolic imbalances
only

• Chemoreceptors respond to changes in H+

concentrations  alters respiratory rate and
depth

• Remember CO2 is an acid

 Respiratory Compensation
• Respiratory Rate will…
– Increase when blood H+ is increased (acidic pH)
• CO2 is “blown off”
• Amount of acid in blood is decreased
– Decrease when H+ is decreased (alkaline pH)
• CO2 is retained
• Amount of acid in blood is increased
 Respiratory Compensation
• This means
– Metabolic acidosis causes an increase in rate and
depth of ventilation as the body attempts to get
rid of acid (CO2)

– Metabolic alkalosis causes a decrease in rate and

depth of ventilation as the body attempts to retain
acid (CO2)
 Renal Compensation
• Used to compensate for respiratory
imbalances
• Remember: HCO3- is a base
• Kidneys respond to changes in blood pH
– Excrete H+ and retain HCO3- when acidemia is
present
– Retain H+ and excrete HCO3- when alkalemia is
present
 Renal Compensation
• This means
– A respiratory acidosis will make the kidneys
excrete acid (H+) and retain base (HCO3-)

– A respiratory alkalosis will make the kidneys

excrete base (HCO3-) and retain acid (H+)
 Renal Compensation
• This is the slowest compensation

• May take hours to days

• Most powerful method of compensation

• Ineffective in patients with renal failure

 Note on Compensation

The body is very smart and will not

overcompensate for an imbalance
 NANDA Nursing Diagnoses
• Fluid and Acid-base Imbalances as Etiology
– Impaired Oral Mucous Membrane
– Impaired Skin Integrity
– Decreased Cardiac Output
– Ineffective Tissue Perfusion
– Activity Intolerance
– Risk for Injury
– Acute Confusion
 Desired Outcomes
• Maintain or restore normal fluid balance
• Maintain or restore normal balance of
electrolytes
• Maintain or restore pulmonary ventilation and
oxygenation
• Prevent associated risks
– Tissue breakdown, decreased cardiac output,
confusion, other neurologic signs
 Nursing Interventions
• Monitoring
– Fluid intake and output
– Cardiovascular and respiratory status
– Results of laboratory tests
• Assessing
– Client’s weight
– Location and extent of edema, if present
– Skin turgor and skin status
– Specific gravity of urine
– Level of consciousness, and mental status
 Nursing Interventions
• Fluid intake modifications
• Dietary changes
• Parenteral fluid, electrolyte, and blood replacement
• Other appropriate measures such as:
– Administering prescribed medications and oxygen
– Providing skin care and oral hygiene
– Positioning the client appropriately
– Scheduling rest periods
 Promoting Fluid and
Electrolyte Balance
• Consume 6-8 glasses water daily
• Avoid foods with excess salt, sugar, caffeine
• Eat well-balanced diet
• Limit alcohol intake
• Increase fluid intake before, during, after
strenuous exercise
• Replace lost electrolytes
 Teaching Client to Maintain
Fluid and Electrolyte Balance
• Promoting fluid and electrolyte balance
• Monitoring fluid intake and output
• Maintaining food and fluid intake
• Safety
• Medications
• Measures specific to client’s problems
• Referrals
• Community agencies and other sources of help
• Facilitating fluid intake
PHLEBOTOMY
Introduction to Phlebotomy
• Purpose of phlebotomy: collect
blood for laboratory analysis
– Phlebotomy: Incision of a vein
for the removal of blood
Introduction to Phlebotomy, cont.
Needs to be accompanied by a laboratory request
Types of blood collections:
– Arterial puncture:
• To asses blood for
– Oxygen level
– Carbon dioxide level
– Acid-base balance
– Venipuncture
– Skin puncture
 Best practices
• Ensure blood is sampled safely, no exposure to
bloodborne pathogens to patients, health care
workers, environment
• Scope of best practices restricted to infection
control
• Do not address other routine practices:
– labelling
– selecting the right equipment for the right patient
– containers
– protecting the sample from contamination
 Patient Preparation for
Venipuncture, cont.
Most common preparation
– Fasting: Abstaining from food or fluid (except
water) for a specified amount of time
• Usually 12 to 14 hours
• Ask patient to state full name and date of
birth
– Compare with information in patient’s chart
• Label each blood tube
WASH HANDS
 EQUIPMENT: Sterile Tray with:
• Pair of gloves
• Tourniquet
• Alcohol wipes
• Gauze
• VACUTAINER barrel and Needle
• Blood bottles (color coded according to additive e.g. anticoagulant
or preservative)

RULES OF ASEPSIS
Venipuncture Equipment (LO 8.1)
 Equipment Assembly (LO 8.1)
• Place equipment near patient
• Line up tubes in order of draw
 Equipment Assembly (cont.)
(LO 8.1)

• Screw needle into adapter

• Insert first tube into tube adapter
Double-ended Evacuated Evacuated
Needle Holder Tube

Needle
Placed
Bevel-Up

Assembled Venipuncture Set

 STEP 2: CHECK PATIENT DETAILS

• Ask full Name, DOB, and compare with blood

request form!

• If special requirements, check patient has complied,

e.g. fasting!

• Have you had blood taken before? (preferred vein)

WASH HANDS
Application of the Tourniquet

• Purpose: makes patient’s veins

stand out so that they are easier
to palpate
• Causes venous blood to slow
down and pool in veins in front
of tourniquet
– Makes veins more prominent
• More visible
• Can be palpated
Application of the Tourniquet,
cont.
Guidelines for applying the
tourniquet
– Do not apply over sores or
burned skin
– Place 3 to 4 inches above bend in
elbow
• Allows adequate room for
– Cleansing site
– Performing VP
 Applying the Tourniquet

Position Tourniquet Cross Left End

Over Right
 Applying the Tourniquet (cont.)

Tuck Left End Under Loose Ends Point

Right End Toward Shoulder
Application of the Tourniquet,
cont.
Never leave on for more than 1 minute
• Uncomfortable for patient
• Causes venous blood to stagnate: venous stasis
– Plasma filters into tissues: causes
hemoconcentration
Always remove tourniquet before removing needle
• If needle is removed first: blood is forced out of the
puncture site causing a hematoma
• Hematoma: a swelling or mass of coagulated blood
caused by a break in a blood vessel
Wipe tourniquet with a disinfectant (alcohol) if reusable
 Site Selection for Venipuncture
• Best site for most patients: veins in
antecubital space
– Easy to draw blood
• Patient with large visible veins
– Difficult to draw blood
• Small veins
• Veins that cannot be palpated
 Selecting the Site (LO 8.1, LO 8.2)
• Position arm at
downward angle
• Ask patient to make
a fist
• Examine antecubital
area first
• Palpate vein with
fingertip
Antecubital Veins
Site Selection for Venipuncture,
cont.
• Cephalic: second choice
– Does not roll and bruise as easily as basilic
• Basilic: last choice
– May cause injury to underlying structures
1) In some individuals: branches of median nerve lie
close to basilic
Site Selection for Venipuncture,
cont.
Thoroughly assess vein
• Place one or two fingertips over vein
– Index and middle finger
• Press lightly: then release pressure
• Suitable vein: feels round, firm, elastic, and engorged
– When an engorged vein is depressed and released: springs
back in a rounded, filled state
Site Selection for Venipuncture,
cont.
Techniques to make veins more prominent
• Remove tourniquet and have patient dangle arm over
side of chair for 1 to 2 minutes
• Tap vein site sharply with index finger and second
finger
• Gently massage arm from wrist to elbow
• Apply warm, moist washcloth for 5 minutes
 Alternative Venipuncture Sites
• Alternative sites
– Inner forearm
– Wrist area above thumb
– Back of hand
Alternative Venipuncture Sites
 Alternative Venipuncture Sites,
cont.
4. Use veins in hands as a last resort:
– Have a tendency to roll because:
• Not supported by much tissue
• Close to the surface of the skin
– Makes them more difficult to stick
Abundant supply of nerves in hand
• Makes procedure uncomfortable for patient
b. Thin walls
• Make them susceptible to:
– Collapsing
– Bruising
– Phlebitis
 Put Gloves on.

Ensure patient is in a relaxed position.

• Use aseptic
technique
– Use antiseptic
(70% alcohol pad)
– Use concentric
circles
– Begin at the site
and move outward
• While cleansing, apply sufficient pressure to remove surface dirt.
• Allow the alcohol to dry completely before continuing with venipuncture. If the
alcohol has not completely evaporated when you perform the venipuncture, the
alcohol may mix with the specimen, causing hemolyzation and affecting test results.
• Do not blow on or fan the site to hasten the alcohol drying process.
• Stretch skin and insert needle at 15-30
degrees parallel into the vein
(bevel edge of needle facing up)

15-30 degrees
• Introduce VACUTAINER bottle into the barrel.

• Allow blood to collect. It will automatically

stop filling when full.

• NB: Different colour bottles contain different additives and

anti-coagulants etc!
 Collecting the Specimen (LO 8.1)
• Insert the first
evacuated tube to
start blood flow
• Hold equipment
steady during tube
changes
• Allow each tube to fill completely
• Mix tubes with additives immediately
• To change tubes, brace the thumb against the flange of the
holder and remove the tube with a pulling and twisting
motion.
• Be sure to use the correct draw order. Placing the tubes in the
proper order before you begin will help ensure this.
• If you are collecting specimens into tubes that contain
additives, mix the tubes by inversion. Invert the tubes the
number of times recommended by the manufacturer, usually
8 to 10 times.
 Types of Blood Specimens
• Type of blood specimen required: depends
on type of test to be performed
– Examples:
• Serum: required for most blood chemistry studies
• Whole blood: required for a complete blood count
(CBC)
Types of Blood Specimens
Types of Blood Specimens, cont.
Whole blood: Obtained from tube
containing an anticoagulant to prevent
clotting of blood cells
– Tube must be gently rotated 8
to 10 times after collection
• To mix anticoagulant with blood
 Types of Blood Specimens, cont.
Plasma: obtained from whole blood that has been
centrifuged
– Because tube contains an anticoagulant,
separates into:
• Top layer: plasma
• Middle layer: buffy coat (white blood cells and
platelets)
• Bottom layer: red blood cells (RBCs)
 Needle, cont.
4. Gauge sizes for VP: 20 to 22
– 21 gauge: most commonly used
– 22 gauge: recommended for children and
adults with smaller veins
– 20 gauge: when a large volume tube is used
 Needle, cont.
5.Length of needle: 1 inch and 1½ inches
– Length used: based on individual preference
• 1 inch:
– Less intimidating to patient
– Offers more control during stick
• 1½ inch:
– Allows more room for stabilizing the vein
 Plastic Holder

• Consists of
plastic cylinder
with two
openings
– Small opening:
used to secure
needle
– Large opening:
holds evacuated
tube
Rubber Stopper Evacuated Tubes
Hemogard Closure Evacuated
Tubes
 Order of Draw for Multiple Tubes
• Blood culture tube
– Drawn first to prevent contamination by other
tubes
2. Coagulation tubes (light blue)
– Prevents additives from other tubes from
getting into the tube
• Make sure to completely fill coagulation tube to
exhaustion of vacuum
‒ To prevent erroneous test results
 Order of Draw for Multiple Tubes,
cont.
3. Serum tubes
– Includes:
• Tubes with or without a clot activator
• Tubes with or without a gel barrier
– Prevents contamination of serum tubes by
tubes with an anticoagulant
To make a puncture:
– Use a •The bevel must be facing up.

continuous
steady motion
• At a 15-degree
angle to
patient's skin
Do not use:
• Slow timid motion
– Painful to patient
• Rapid, jabbing motion
– Painful to patient
– Could cause needle to go through vein
resulting in:
1) Failure to obtain blood
2) Hematoma
Remove last tube
from plastic holder
before removing
needle from vein
– Prevents blood
from dripping
out of needle
after
withdrawing it
• FIRST Remove blood BOTTLE

• THEN remove TOURNIQUET

• LASTLY, swiftly remove NEEDLE

• Safely dispose needle to sharps bin

immidiately –NEVER RESHEATH!!
Completing the Procedure
• Apply gauze to puncture site for 1 minute,
with some pressure.

• Remove gloves and wash hands

Mix tubes containing anticoagulant immediately after drawing
– Rotate tube gently 8 to 10 times
• Provides adequate mixing without causing
hemolysis
• Hemolysis: the breakdown of blood cells
– Shaking tube: can result in hemolysis
b. Clotting of blood can be caused by:
• Not mixing tubes immediately
• Inadequate mixing
– May cause inaccurate test results
Plasma
Microcollection Devices
• Specimen may be placed
directly onto a reagent strip
– Example: blood glucose monitors
• May be collected with a
microcollection device
– Device used depends on
laboratory equipment being used
• Examples:
– Capillary tubes
– Microcollection tubes
 Capillary Tubes
• Consists of
disposable glass
or plastic tube
• Depending on
size: can hold 5 to
75 µL of blood
• Used for
hematocrit
determination
IV
Six Rights of IV Fluid Administration
• Right Patient: treat as any drug, use MAR for
accuracy in administration
• Right Drug: solution for IVs
• Right Dose: consider w/time, Amount of IV
solution to hang
• Right Time: rate of solution administration
• Right Route: specific order for IV admin
• Right Documentation: Always!!!!
 Right Solution
• Per physician orders
– Common solutions: 0.9NS, 0.45NS, D5W, D5/.2NS,
D5/.45NS, LR/RL (Lactated Ringers or Ringer
Lactate)
• Inspect Integrity of packaging
• Inspect fluid for clarity and absence of
particulate matter
• TPN, Lipids, albumin, blood, > 20mEq KCl or
“K-Riders”
Right Dose (Amount) & Time (Rate)
• Amount:
– - per physician’s orders
– - amount of solution
• - order may include a specific number of liters
or mL’s of a specific Solution
• Rate:
– - per physician’s order
 When is the right time to
hang a new IV bag?
• When the last IV is near empty
• There is a change in orders for the solution
• only 24hrs
• Check status of IV during initial assessment –
Plan ahead, be prepared in advance!!
 Equipment: Infusion Administration
Sets (Primary Tubing)
• Features:
– – Spike w/cover
– – Drip chamber
– – Pump cassette – specific to machine
– – Y sites
– – Roller clamp
– – Slide clamp
– – End adapter w/cover
 Controllers
• Thru peripheral IV sites-depend on gravity for
administration- must be 24-36 inches above IV
sites
• If patient changes positions volume
decreases-back pressure greater, rate slows or
stops
• Simplest controllers-roller or slide clamp
• Use to speed up or slow, counts gtts in drip
chamber
 Equipment: Infusion Administration
Sets (Primary Tubing)
• Check integrity of packaging
• – Sterile system –
– therefore you must maintain sterility of the spike
and capped adapter end.
• Policies for when to change IV infusion set
(tubing)
• Change tubing labels
 Regulation of Infusion Rate
• Methods of Infusion:
• 1. Mechanical Pumps – preferred
• 2. Gravity – no pump, control by clamp
• • Pumps control by sensors at cassette
• Set: Volume to be infused – 1000ml
• Set: Rate for infusion – 125ml/hr
• • Gravity – pressure on tubing by clamp
• Calculate # of drops/minute, count these
 Infusion by Pumps

• The pump doesn’t think: it does only what you

tell it to do.
• Reasons for alarms from pumps:
• – Air in tubing, sensed at the cassette
• – Occlusion anywhere in system
• – Volume to be infused completed
• • Advantages of pumps
• – Accurately delivers set rate
• – Alerts us if problems occur
 Infusion by Pumps
• Types of Occlusions
• • #1 - Human error : roller clamp still closed
• • Bent or kinked tubing
• • “Positional” IV: twist of arm, bent hand
• • IV is no longer patent: infiltration, phlebitis
 IV Site Assessment
• Note the location (hand,wrist, forearm,
antecubital fossa)
• • Site should be visually inspected and
palpated q 2hr
• The IV site should be free of redness, swelling,
tenderness
• The IV dressing should be clean and secure
 Infiltration/Extravasation
• Assessment
• – Swelling
• – Pallor
• – Coolness
• – Discomfort
• – Sluggish flow
 Infiltration/Extravasation
• Nursing
• Intervention
• – Discontinue IV
• – Elevate if possible
• – Warm Compress
• (not hot! hot!)
 Phlebitis
• Assessment
• – Redness
• – Swelling
• – Warmth
• – Pain along vein route
• – Vein is hard “cordlike”
• – IV may be sluggish
 Phlebitis
• Nursing Interventions
• – Do not flush!!
• – Discontinue IV
• – Warm compress
 Infection - Local, Systemic
• Assessment
• – Redness, swelling, pain at site
• – Pus at site
• – Fever, chills
 Infection - Local, Systemic
• Interventions
• – Prevention!! Adhere to policy for site change
and site care.
• – Use appropriate technique for IV starts and
site care.
• – Once it occurs, involve physician,
discontinue IV and Rx infection per orders.