We will be discussing Fluid Therapy, which is a major part of nursing school and the NCLEX. We will also be going over some great tips, and tricks for nursing school and the NCLEX!
***=might show up on the NCLEX Hey guys this is Cindy. I'm one of the nurses here at NCLEX Mastery. And today we're going to talk about fluid replacement. This is a major part of the NCLEX and also a really important part of your nursing practice. I'm going to start out by reviewing principles and concepts related to fluid replacement, types of fluid and what they're used for. Then I'll give you some tips specifically for doing well on the NCLEX. And I'll wrap it up with some great tips for you in your clinical practice and some shortcuts. So fluid replacement is providing fluid and electrolytes to clients who have alterations, including dehydration. So remember that anytime a client is in the hospital they are at risk for fluid volume deficit or fluid volume excess due to receiving fluids and medications, alterations in elimination, or decreased intake. Fluid volume deficit is caused most commonly by vomiting, fever, blood loss, drainage from wounds sites, diarrhea or diuretics. Common causes of fluid volume excess or too much fluid is caused by high dietary sodium, certain medications, kidney or heart failure, or too much I.V. fluid or too fast a rate of I.V. fluid. So clearly nurses are in a good position to optimize fluid replacement. So we know that fluid replacement is a big part of our jobs as nurses and we need to offer fluids, but what kind? There are two main types of fluid crystalloids have salts that dissolve easily in them. They're usually clear and thin. Colloids contain larger molecules like protein molecules and they don't dissolve very readily. We're going to learn in a couple of minutes which specific fluids are used most commonly and what they're used for. But why do we care if things dissolve or they don't? If you think back to grade school and the terms osmosis and diffusion these terms pertain to the movement of fluid and electrolytes. The movement of fluid and electrolytes from one space to another within the body is one of the most important things to keep in mind when providing I.V. therapy. The terms for different I.V. fluids are all in relation to our plasma which has a certain osmolality, a certain concentration. Fluid is gained and lost all day long and hydration or the combination of solids with water in our bodies results from homeostasis or balance. So let's cover some important terms first. So important terms: osmosis. Osmosis refers to active particles in a given volume of water. Osmolality Is directly related to the term osmosis. This is a great way to remember the term osmolality because most of us learned about osmosis back in grade school which is the transmission of water across a semi permeable membrane for low solute concentration to high solute concentration. So you can measure osmolality of any fluid in the body, but blood and urine are the most common and you will see this on lab reports. Viscosity is another term. It refers to the resistance of fluid to pressure. So it's a thickness or how smoothly it moves through a space. Dehydration literally means without water. Isotonic is another important term. Isotonic refers to the same osmolality or osmo as our plasma. Isotonic fluids are the most common fluids because they mirror the same osmolality as plasma. So of course our first action for many clients we want the least invasive plan to rehydrate is to offer oral or enteral fluids you'll hear the terms oral or enteral. So for clients unable to ingest solid food sometimes they can still drink liquids and this is our first approach to rehydration. It's always preferred, but a lot of clients do require I.V. fluids because they can't get enough by mouth. The most common type of dehydration as we mentioned is isotonic and it's caused by vomiting or diarrhea most commonly. This leads to loss of fluid from the extracellular compartment. So less fluid is in vascular circulation. So how do we hydrate these clients? Surprise, we give them the isotonic fluids they're losing in equal amounts and we want to add back with the fluid that resembles our own fluid. So as you guessed these fluids have the same concentration as plasma and they are the most common IV solutions. The most common are normal saline and lactated ringers. Both of these contain the same mix of electrolytes and fluid similar to our own plasma. Normal saline has sodium chloride. Plain ringer's solution has sodium, chloride, potassium, and some calcium. But lactated ringer's contains the same as ringer's, so sodium, chloride, potassium and calcium but it also adds lactate. The reason why is that lactate is converted by the liver to bicarb. So it's a common solution used for those at risk for metabolic acidosis. By far the most common fluid used in clinical practice is normal saline. Now D5W or five percent dextrose in water is also a fairly common fluid especially for mixing medications in the pharmacy. It is isotonic at first, but once the glucose is metabolized it adds free water and increases fluid volume in both the intracellular fluid and extracellular fluid. So wrapping up talking about isotonic fluids. The risks for isotonic fluid administration is mainly hypervolemia because you're putting these fluids that are not likely to move around a lot into the vessels. So things to watch for include bounding pulse and shortness of breath. You want to avoid using these fluids for those with increased intracranial pressure because it can lead to cerebral edema. You also want to avoid giving these fluids too fast to those with kidney or heart failure. The next most commonly used fluids are hypotonic fluids. They have a lower osmo than plasma so cells draw water in and swell when these fluids are given. They provide free water and they treat cell dehydration. They promote waste elimination through the kidneys. These fluids include half normal saline or a third normal saline and they are abbreviated .45% saline or .33% saline when they're written in the order. You want to avoid giving these to those with increased intracranial pressure or any third spacing because these fluids increase the movement of fluid at the cellular level. Because these solutions are less concentrated than normal saline they will cause fluid to shift into the cells and this can cause swelling. These fluids include 5% dextrose and it's mixed in either normal saline half normal saline or lactated ringers. The abbreviations for these are D5NS, D5 1/2NS or D5LR. You want to exercise caution with these fluids because they can cause hypervolemia. So you want to watch for signs of tachycardia and bounding pulse. You should avoid these with clients with kidney or heart disease or acute dehydration. It's worth noting that there are fluids called volume expanders. They're used for severe losses like Burns or hemorrhage. These include dextran plasma and serum albumin which replaces lost proteins, but these are less common. Okay, as promised here's your tips for the NCLEX. Know that intravascular refers to blood plasma. Know that interstitial fluids surround cells and makes up length. Know that trans cellular fluid makes up everything else. This includes cerebrospinal, pleural peritoneal, and synovial joint fluid. Any fluid with a higher solute, think solid particles, increases osmotic pressure or osmosis and draws water to reach a balance. The average fluid output for an adult is 1300ml's daily or about 50 to 60 m's per hour, the minimum being about 30 ml's per hour. Commit that to memory for the NCLEX. Push fluids means increased the fluids ordered. Restricted fluids are prescribed for fluid retention, fluid volume excess. So too much fluid in circulation. These clients often have weak hearts and kidneys that can't keep up. These orders can vary from NPO or nothing by mouth to specific dietary amounts. An order may state fluid restriction 1,500 ml's daily. This means they cannot have more than that amount and the nurse should be keeping track. Two medication classes that affect hydration because of their actions in the kidneys are corticosteroids, which increase calcium loss, and diuretics which increase potassium loss. Another tip: lab tests on extracellular fluid or blood do not reflect what is going on inside the cells. So remember that only what is in circulation is being tested and reported on lab tests. Ask yourself what is happening at the cell level or in the kidneys to compensate to create those values and always pay attention to abnormal values in your exhibit items that present a client's medical record. Remember the organ that maintains fluid balance is the kidney, period. It eliminates waste and regulates electrolytes, which in turn regulate fluid. Movement of fluids happens easily in capillaries, but it doesn't happen easily in larger vessels in circulation. This is why third spacing is such a problem. The fluids between cells and inside vessels are almost identical except for larger protein molecules, albumin, found in vessels. This is what contributes to third spacing. It results from tissue damage. And the last tip for the NCLEX is there should always be a rate of fluid infusion for any orders that have fluids. Even though in practice we use the term KVO or keep vein open in, terms of the NCLEX you'll always expect to see an actual rate stated on the order. Okay, now for clinical practice tips. These will help you in your everyday practice once you pass the NCLEX. You will always treat acute fluid loss such as hemorrhage with normal saline or lactated ringers at a bolus rate. At least at the beginning. Another tip: remember that one liter of 5% dextrose equals about 170 calories. Also remember that giving warmed isotonic I.V. fluids from a fluid warmer is common, especially in areas where fluid must be given fast, such as the emergency room. This is way more comfortable than getting normal saline that's at room temperature. Another tip: always use a pump. Most facilities require pumps for any routine I.V. fluids to prevent the risk of fluid volume access. Keep in mind that a lot of facilities have smart pumps and those pumps have built in settings which may not allow you to prescribe a certain rate. Always double check your orders, always check with the pharmacy if you have questions, and follow the prompts for the smart pump. Only fill the drip chamber a third full when you're setting up your I.V. so you can visualize the drip rate. This is a great second check on the rate as you will get to know quickly what a 100 ml's per hour looks like. To check for contamination or sediment hold the bag against a dark background. This will help you see the color. Another tip: I.V. bags are wrapped in an outer plastic bag that may have visible droplets of condensation. This is perfectly normal. If you squeeze the drip chamber a little while you're spiking a bag you will prevent air from entering the bag. It's okay if air enters the bag, but this is a nice tip. Dehydration can lead to acute kidney injury. Adults require at least 500 ml's of intake daily just to filter waste from the body. Remember that nurses play a critical role with regard to I.V. fluid therapy. For more tips to master the NCLEX and more podcasts go to nclexmastery.com