N205 INTRAVENOUS THERAPY AND AIDS
Objectives: Upon completion of this class, the student will be able to:
1. Correlate the pathophysiologic alterations with the manifestations of HIV/AIDS infection;
2. Discuss normal regulation of fluids and electrolytes;
3. Describe the regulation of acid-base balance;
4. Discuss nursing responsibilities with IV therapy;
5. Describe nursing responsibilities with IV sites, IV tubing, and IV solutions;
6. Demonstrate correct technique for calculating drip rate of IV solutions.
I. AIDS: acquired immune deficiency syndrome
HIV: human immunodeficiency virus
From exposure to body fluid that’s infected/contaminated; vaginal secretion, breastmilk, blood, etc.
A. Pathology
1. Retrovirus infects cells with CD4 antigen [T–Helper cells and macrophages]
No longer a fatal disease but a chronic disease.
2. Enters cell and converts RNA to DNA with reverse transcriptase
3. HIV DNA integrated into host DNA
4. duplication of HIV during cell division
5. virus buds from cell surface, destroys host cell and spreads—you are left without enough surveillance in the body.
B. Manifestations
1. Primary HIV infection: flu like symptoms
2. Asymptomatic infection: no symptoms now but you become sero-positive—you’ve made antibodies that show up on a blood test.
3. Persistent generalized lymphadenopathy [lymph-gland-disease]
4. Acute symptoms: fever, weight loss, night sweats [like TB],
5. Opportunistic infections and cancer: as the CD4 cells die off, you’re up for all sorts of infections that are life threatening or not—cancers like Kaposi’s sarcomas.
Symptoms: stomatitis [sores in the mouth]
C. Diagnosis
1. CD4 T cell count
2. clinical symptoms
3. viral load
Nurse’s job: how do you know someone’s positive? It should be in their Hx, they should divulge it. It’s illegal to test for HIV w/o pt permission—whether a preop concern or a needlestick injury.
D. Interdisciplinary Care
1. Medications: reverse transcriptase inhibitors, protease inhibitors, HAART
2. Prevention
3. Assessment
4. Nursing Diagnoses: list four
Knowledge deficit r/t new diagnosis, community resources, AEB asking questions
Risk for infection r/t immunodeficiency
Anxiety r/t diagnosis, AEB frequent questions
Inbalanced nutrition r/t stomatitis, anorexia, nausea
Ineffective sexual patterns
Social isolation
5. Standard Precautions for healthcare provider safety
After today we hang piggyback’s and hang IV’s.
II. Body Fluids
Where is body fluid- interstitial and intracellular, somewhat extracellular, and we can’t really measure that.
How can you tell if someone is balanced or out of whack?
Assess:
Edema; fluid retention. Not as much output as input.
Capillary refill
I & O
A. Components
B. Movement
1. Osmosis
2. Diffusion
3. Filtration
C. Regulation: fill the tank or empty the tank
1. fluid intake
2. fluid output
3. maintaining homeostasis: who controls it? Kidneys, juxtaglomerular apparatus triggers the RAA, ADH, Aldosterone from hypothalamus/pituitary. Thirst center—people who don’t have thirst centers are low LOC people, and elders whose neurons are just old.
Normal potassium level should be around 3.5-5.0 , depending on the lab. Margi might test us on this.
What causes hyperkalemia? Supplements [micro K]
D. Regulation of Electrolytes
1. Why is this important?
2. What are they?
3. What do they do?
E. Acid Base Regulation: who does it? Look in the book at this, we will be tested on most normal blood gas abnormality [resp acidosis from hypoventilation] and on common lab values. The lungs and the kidneys.
1. Metabolic buffers
2. Respiratory Regulation
Lungs: blow off CO2 from cellular respiration:
CO2+H2O à H2CO2 à H+ à high H+
Hypoventilation means high CO2 holding which means high acid in the blood.
Cheyne-stokes respirations: a type of hyperventilation that blows off CO2
Blood gas values are covered in the book.
ABG’s: dissolved pressures of CO2 or O2 in arteries, not in veins. Normals:
pH: 7.35-7.45
pCO2: 35-45
pO2: 80-100
saO2: >95%
Bicarb: 22-26
3. Renal regulation
Kidneys: provide bicarbonate buffer system for the body. These take hours to days to make blood pH effects.
CBC tells us: WBC count. Check the electrolyte labs. CBC we really care about: BUN/Creatinine, H&H [hemoglobin and hematocrit]
F. Factors affecting body fluid, Electrolytes, Acid-base balance
1. Age: why?
2. Gender and body size-why?
3. Lifestyle-why?
4. Environmental temperature-why?
G. Fluid imbalances
1. Deficit
2. Third space syndrome
3. Excess
4. Edema
5. Dehydration
6. Overhydration
H. Electrolyte imbalances: Memorize the normal values for these, the symptoms of hypo and hyper’s
1. K
2. Na
3. Ca
4. Mg
5. Cl
6. PO4
Margi’s memorization of ABG’s: she memorizes the midpoint of all the ranges
7.4 [ph]
40 [CO2?]
100 [o2]
25 [bicarb]
100 [?]
I. Acid-base imbalances
1. Respiratory acidosis from hypoventilation (know this one)
2. Respiratory alkalosis from hyperventilation
3. Metabolic acidosis from excess body acids
4. Metabolic alkalosis from excess body bases
III. Nursing Management
A. Assessment:
1. History
2. PE
3. Daily weights
4. I & O
5. VS
6. Labs
B. Nursing Diagnoses: list four
C. Planning
D. Implementation
IV. IV Infusions
Who gets IV? Fluid managements, medications IV [esp antibiotics: by IVPB.]
Normal saline: 0.9%
Once I set up a piggyback bag: it needs to be labeled: pt, dose, time, date, my initials
A. Calculating Drip Factor
1. Nursing Responsibilities: calculate correct IV flow rate; regulate infusion; monitor client’s responses
Not all pts have IV machines hooked up—it drips w/o regulation. Ambulances don’t get these machines either. This is why you have to memorize how to calculate IV drip rate by hand. This will sometimes show up on entrance tests to hospitals.
You have to know the drip rate, and the drop factor on your bag. Drop factor is affected by the tubing diameter. So…the drop factor is the # of drops to deliver one mL of fluid in that particular tubing.
2. IV control device: know how to work it!!
3. Drip factor: drop factor: printed on package of IV tubing
· macrodrop: 10, 15 drops/ml
· microdrop: always 60 drops/ml
4. Calculate milliliters/hour
· divide total infusion volume by total infusion time in hours
· example: 1L over 8H. Divide 1000 ml by 8; equals 125 ml/hr
5. Calculate drops/minute:
a. Drops/min= total infusion x drop factor
total time of infusion in minutes
b. example: Infuse 1000 ml in 8 hours and the drip factor is 20 drops/ml
1000 ml x 20 = 41 drops/min
8 x 60 min (480 min)
6. . Factors affecting flow rate
· position of IV site
· position of tubing
· height of IV bag
· infiltration of IV solution or fluid leakage
B. Changing IV tubing or solution
1. Perform hand hygiene
2. set up necessary equipment
3. maintain sterile technique
4. flush new IV tubing with solution
5. attach to IV catheter
6. infuse at prescribed rate
IV’s are an RN function; LVN’s don’t typically do them.
If the machine is beeping; silence it while you problem solve.
The machine will freak out if there’s air in the line; it will tell you what’s going on and it will not run.
Hanging a piggy back bag: check the date of the tubing. make sure you have set the rollerclamp open on the IVPB, hang it higher than the IVF bag.
Primary vs secondary tubing.
Incompatibility issues: come up when 2 meds are in the same container. Not a problem running them sequentially in the same tubing. “Y site” incompatibility means don’t mix in the same tubes. Gentomycin is not compatible with anything.
Back flushing: to get air out of the tube. Do a little gravity thing—turn the tube upsidedown—this flushes from the Saline bag up to the piggy back. Back flush when hanging Gentomycin after Vancomycin and you want to re-use the tubing.
Why do docs order different fluids? Because they have their favorite flavors—its not about what the pt needs. Surgeons always order LR. Post op is often Dextrose which might be a good thing. We need to know why they are on which fluid.
Which fluid? Most people get isotonics. Sometimes people get a 3% NS, because their sodium is really low—or they want water out of the tissue for whatever reason. Colloids are hypertonic to pull water into the vessels in septic situations, etc. NS be cautious with CHF, perhaps.
Tubing can now be changed every 4 days, according to the CDC, some hospitals are different—some say 2 days. The CDC says 72 hours is the shortest amount of time b/c you’re interrupting the system and creating opportunity for infection. TPN: new bag, new tubing—b/c it’s like nutritional broth for bugs. Don’t put old tubing into a new site. If no label, assume its too old.
C. Nursing Responsibilities with IVs
1. Site patency
2. Correct IV solution and rate
3. client response to IV fluids
4. prevent complications
My job if pt has IV: I need to know the solution as MD ordered, if they still need that solution—is that solution the best for that pt with the current state. Make sure site is patent. Make sure rate etc are also appropriate. RN is still accountable for delivering an inappropriate order—even IVF. Make sure no infiltration—that it’s going iv, not intra tissue!
Site is sterile, inside of bags and tubes is sterile.
Do you need gloves on to hang IV? No.
D. Complications of IV Therapy
1. Phlebitis
2. Infiltration of solution
3. Extravasation of medication
4. Infection at site
No comments:
Post a Comment