for the basic IV therapy for nursing practice, regards the discussion on intravenous fluids, electrolytes, and total parenteral nutrition rsm, md

6. BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FLUIDS AND ELECTROLYTES: Problems/Imbalances Common IV Solutions

7. ?

45. Laboratory Values Used in Evaluating Fluid and Electrolyte Status 3.5-5.5 g/dL 3.5-5.5 g/dL Serum Albumin 3.9-6.1 mmol/L 70-110 mg/dL Serum Glucose Volume fraction: 0.39-0.47 Female: 39-47 % Volume fraction: 0.44-0.52 Male: 44-52 % Hematocrit 10:1 BUN/Creatinine ratio 62-133 mmol/L 0.7-1.5 mg/dL Serum creatinine 3.5-7 mmol/L of urea 10-20 mg/dL BUN 280-295 mmol/L 280-300 mOsm/kg Serum osmolality 24-30 24-30 Carbon Dioxide content 96-106 96-106 Serum Chloride 0.80-1.5 2.5-4.5 Serum Phosphorus 0.80-1.2 1.5-2.5 mEq/L Serum Mg 2.1-2.6 8.5-10.5 mg/dL Total serum Ca 3.5-5.5 3.5-5.5 mEq/L Serum K 135-145 mmol/L 135-145 mEq/L Serum Na SI Units Usual Reference Guide Test

46. Laboratory Values Used in Evaluating Fluid and Electrolyte Status < 6.6 < 6.6 typical urine 4.5-8.0 4.5-8.0 Urinary pH 500-800 500-800 mOsm/L typical urine 40-1400 mmol/kg 50-1400 mOsm/L extreme range Urine Osmolality 1.010-1.020 random specimen with normal intake Physiologic range after fluid restriction: 1.025-1.035 1.025-1.035 Urinary Specific Gravity 110-250 110-250 mEq/day Urinary Cl 40-80 40-80 mEq/day Urinary K 50-220 mmol/day 50-220 mEq/day Urinary Na SI Units Usual Reference Guide Test

57. Types of Fluid Balance And Imbalance

147. FLUIDS AND ELECTROLYTES Elevate pH with IV NaHCO 3 Oral bicarbonate or citrate in chronic metabolic acidosis Improvement of ventilation through bronchodilators or mechanical support For severe type, infusion of NaHCO 3 to raise the pH toward normal THERAPY Decreased HCO 3 ion concentration, hyperventilation (compensatory mechanism), headache, abdominal pain, confusion, drowsiness, lethargy, stupor, coma, arrhythmias Increased pCO 2 , headache, blurred vision, disorientation, tachycardia, cardiac arrhythmias, lethargy, somnolence MANIFESTATIONS Acid accumulation by ingestion, by increased metabolic acid production, by utilization of abnormal or incomplete metabolic pathways, by impaired acid excretion, and primary decrease of HCO 3 Decreased gaseous exchange Impaired neuromuscular function Suppressed ventilatory mechanism on brain stem (medulla) CAUSE METABOLIC (Noncarbonic acid excess) RESPIRATORY (Carbonic acid excess) ACIDOSIS

148. FLUIDS AND ELECTROLYTES Directed toward treating the original cause and enhance the renal excretion of bicarbonate to correct imbalance Dialysis may be instituted if profound Correct the underlying disorder Monitor for its effectiveness and potential complications THERAPY Initial disorder, nausea, emesis, paresthesias, tetany, seizures, profound disorder, confusion, lethargy, coma Decreased pCO 2 , diaphoresis, lightheadedness, paresthesias (fingers, toes, circumoral), muscle cramps, Chvostek ’s and Trosseau ’s sign, carpopedal spasm, tetany, syncope, arrhythmias MANIFESTATIONS Decreased of acid Increased of base (bicarbonate ions) Hyperventilation CAUSE METABOLIC (Noncarbonic acid deficit) RESPIRATORY (Carbonic acid deficit) ALKALOSIS

149. FLUIDS AND ELECTROLYTES B. Isotonic Fluid: Osmolality = 240 – 340 mOsm/L, treat hypotension due to hypovolemia Ringer’s lactate, blood components, 0.9% NaCl C. Hypertonic Fluid: Osmolality 340 mOsm/L or higher 5% Dextrose in 0.45% NaCl, 5% Dextrose and 0.9% NaCl, 10% or 20% or 50% Dextrose, 3% and 5% NaCl, hyperalimentation Blood and blood products Stabilized human serum (SHS) Haemacel Human albumin Plasma protein fraction (PPF) A.Hypotonic Fluid: Osmolality < 240 mOsm/L, lowers serum Na 0.45% NaCl, 5% Dextrose Water, 0.2% NaCl Solutions that do not dissolved Not true solutions Increase intravascular colloid osmotic pressure True solutions Capable of passing through a semipermeable membrane COLLOID SOLUTIONS CRYSTALLOID SOLUTIONS TYPES OF INTRAVENOUS SOLUTIONS

150. Osmosis. Erythrocytes undergo no change in size in Isotonic solutions (A). There is increase in size in Hypotonic solutions (B) and decrease in size [shrink/crenate] in Hypertonic solution (C).

154. Thank You ! Dr. Ronald Sanchez - Magbitang

155. BASIC INTRAVENOUS THERAPY TRAINING PROGRAM TOTAL PARENTERAL NUTRITION (TPN) Solutions Used in TPN

156. ?

164. PARENTERAL NUTRITION Hill et. al. (1977) Lancet 1: 687

177. PARENTERAL NUTRITION < 70% 70 – 79% 80 – 90% % ideal body weight anergy reactive reactive Cell – mediated immunity < 800 800 - 1199 1200 - 2000 Total lymphocyte count, mm 3 > 10% over 6 months > 7.5% over 3 months > 5% over 1 month Weight loss < 100 100 - 149 150 - 200 Transferrin, mg/dL < 2.1 2.1 – 2.7 2.8 – 3.4 Albumin, g/dL < 80% 80 – 89% 90 – 95% % usual body weight Severe Moderate Mild PROTEIN – CALORIE DEFICIENCY

183. PARENTERAL NUTRITION Bistrian BR, et.al. Cellular Immunity in semi-starved states in hospitalized adults. Am. J. Clin. Nutr. 1975; 28: 1148 Elwyn DH. Nutrional Requirements of Adult Surgical Patients: Crical Care Medicine 1980; Vol. 8, No. 1: 9-20 Lee HA. Methods of Assessment IN: Johnston IDA and Lee HA, eds Development in Clical Nutrion Tunbridge Wells. MCS Consultants 1979; 75-78 800 – 1200 /mm Moderate malnutrition < 800 /mm 1200 – 2000 /mm Severe malnutrition Mild malnutrition TOTAL LYMPHOCYTE COUNT 16 - 20 12 - 16 8 - 12 Nitrogen (gms) 2000 – 3000 2000 - 2500 1500 - 2000 Energy (kcals) Highly increased Moderately increased Normal Total Daily Body Requirement GUIDELINES TO ENERGY AND NITROGEN REQUIREMENTS

190. PARENTERAL NUTRITION = 110 – 120 kcal/kgDBW/day 1. Infants 45.0 heavy 40.0 moderate 35.0 light 30.0 sedentary 27.5 bed rest Kcal/kgDBW/day Activity Level: Kraus Method 4. Adults: * Average for both sexes = 50 kcals/kgDBW/day 45 50 16 – 19 years old 50 55 13 – 15 years old Girls Boys 3. Adolescents: = 1000 + (100 x age, years) 2. Children ACTIVITY FACTORS

191. PARENTERAL NUTRITION 1.30 – 1.80 Pancreatitis 1.30 – 1.55 Liver Failure 1.30 Acute Renal Failure 1.30 – 1.55 - with major operation 1.20 – 1.30 - with dialysis or sepsis 0.80 – 1.00 - without sepsis Cardioplulmonary Disease 1.20 – 1.30 Bone Marrow transplant 1.30 – 1.35 ARDS or Sepsis 1.05 – 1.25 Peritonitis or other infections 1.00 – 1.10 Elective Surgery 0.80 – 1.00 Starvation Stress Factor Clinical Conditions: DISEASE STRESS FACTORS

192. PARENTERAL NUTRITION Liver failure Severe burn 45 kcals/kgDBW/day Severe Stress Sever infection Fracture 35 kcals/kgDBW/day Moderate Stress Mild infection Elective surgery 25 kcals/kgDBW/day Mild Stress Examples Energy Requirement Simplified Estimate DAILY ENERGY EXPENDITURE

196. PARENTERAL NUTRITION * Rice another food group added by FNRI 100 - 2 23 80 ½ cup *RICE 45 5 - - 5 1 tsp Fat 55 75 3 3 7 7 - - 30 30 1 ounce 1 ounce Meat, low fat Meat,med fat 70 - 2 15 varies Bread 40 - - 10 varies Fruit 25 - 2 5 100 ½ cup Vegetables 80 179 - 10 8 8 12 12 240 240 1 cup 1 cup Milk, non-fat Milk, whole Energy (kcal) Fat (gm) Protein (gm) Carbohydrate (gm) Weight (gm) Measure Food Exchange COMPOSITION OF FOOD EXCHANGE LIST

205. PARENTERAL NUTRITION 20.0 – 120.0 150.0 – 300.0 Molybdenum, μ g 15.0 – 30.0 50.0 – 200.0 Chromium, μ g 2.0 – 5.0 2.0 – 5.0 Manganese, mg 0.15 0.15 Iodine, mg 0.3 – 0.5 2.0 – 3.0 Copper, mg 3.0 – 12.0 15.0 Zinc, mg 1.0 – 2.0 10 Iron, mg 0.3 0.3 Magnesium, gm 3.0 – 4.0 2.0 – 3.0 Chloride, gm 1.0 – 3.0 1.0 – 3.0 Sodium, gm 3.0 – 4.0 2.0 – 5.0 Potassium, gm 0.4 – 0.8 0.8 – 1.2 Phosphorus, gm 0.2 – 0.4 0.8 – 1.2 Calcium, gm 2.0 – 4.0 1.0 – 2.0 Essential fatty acids, % kcal Parenteral Enteral Daily Requirement, Adult range Nutrients DAILY REQUIREMENT OF FATTY ACIDS, VITAMINS, & MINERAL

206. PARENTERAL NUTRITION 200.0 70.0 – 140.0 Vitamin K, μ g 10.0 – 15.0 8.0 – 10.0 Vitamin E, mg 5.0 – 10.0 10.0 Vitamin D, μ g 1000.0 1000.0 Vitamin A, μ g 3.0 3.0 Cobalamin, μ g 400.0 400.0 Folic acid, μ g 4.0 2.0 Pyridoxine, mg 15.0 5.0 Panthotenic acid, mg 60.0 60.0 Biotin, μ g 40.0 18.0 Niacin, mg 3.60 1.60 Riboflavin, mg 3.0 1.40 Thiamine, mg 100.0 60.0 Ascorbic Acid, mg 50.0 – 100.0 50.0 – 200.0 Selenium, μ g Parenteral Enteral Daily Requirement, Adult range Nutrients DAILY REQUIREMENT OF FATTY ACIDS, VITAMINS, & MINERAL

207. ?

212. ?