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Medication and fluid therapy.pptx

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Medication and fluid therapy.pptx

  1. 1. Medication and fluid therapy • A drug is a substance that changes the function of a living organism in some way. • Drugs can be used for pleasure (recreational) or as treatment. • A drug that is used for a therapeutic purpose is called a medication. • Medications are used to diagnose, prevent, and treat various illnesses.
  3. 3. General Guidelines for Safe Medication Administration • Wash your hands. • Prepare medications in a well-lit area. • Always check medication label against order three times (name, dosage strength, route and form, and so on). • Always check for allergies. • Consistently follow the six rights of medication administration. • Give only medications prescribed by a legally authorized person. • Only give medications you have prepared; do not leave medications unattended.
  4. 4. General Guidelines for Safe Medication Administration • Never give a medication with an altered appearance. • Never give a medication that you have concerns about (better to be safe than sorry; check with the pharmacist or prescriber). • Shake medications if required. • Measure medications at eye level. • Use universal precautions and sharps precautions as appropriate. • Safely store medications (separate look-alike, sound-alike medications; label high-alert medications). • Avoid taking short cuts and performing work-arounds. • Always be honest!
  5. 5. Cont.… Handling Medication Errors • Recognize the error. • Stay calm. • Report the error immediately. • Follow the prescriber’s orders for correcting the error. • Document the error according to organizational policy (usually on an occurrence report, not the nurse’s notes).
  6. 6. Nurses play a critical role in the medication administration process. • Although medication administration is a part of the nurse’s daily routine, it is far from being a routine skill. • Medication administration requires knowledge of basic pharmacologic principles, legal requirements, and medication administration principles. • Critical thinking along with the nursing process provides for a safe, effective, systematic approach to medication administration. • A review of the medication rights (right patient, right medication, right dose, right route, right time, and right documentation) should always be included during medication administration.
  7. 7. • Medication actions and effects are influenced by how the medication is absorbed, distributed, metabolized, and excreted by the body. • Medications have intended effects and unintended effects. • The goal of medication therapy is that the patient receives medications that provide the best benefit without unintended effects or with minimal unintended effects. • The nurse provides valuable information to the prescriber for the determination of how this balance can best be achieved. • The nurse is totally accountable for his or her actions as it relates to medication administration, including responsible reporting of medication errors in a timely manner so as to ensure the safety of the patient.
  8. 8. FLUID THERAPY • It is administration of large amount of solution / fluid in to circulatory system through vein. • Intravenous fluids are similarly classified based on their ability to pass through capillary walls that separate the intravascular and interstitial fluid compartments into Crystalloid fluids and Colloid fluid .
  9. 9. Cont.… • Crystalloid fluids are electrolyte solutions with small molecules that can diffuse freely from intravascular to interstitial fluid compartments • Colloid fluid is a saline solution with large solute molecules that do not pass readily from plasma to interstitial fluid. • The retained molecules in a colloid fluid create an osmotic force called the colloid osmotic pressure or oncotic pressure that holds water in the vascular compartment.
  10. 10. The aims of IV fluid administration should be to • Avoid dehydration • Maintain an effective circulating volume • Prevent inadequate tissue perfusion during a period when the patient is unable to achieve • These goals through normal oral fluid intake • “Intravenous fluids have a range of physiologic effects and should be considered to • be drugs with indications, dose ranges, cautions, and side effects.”
  11. 11. CLASSIFICATION I V Fluids Blood and Products Non blood I V Fluids Crystalloids •Glucose Containing •Electrolyte solutions •Mixed Colloids Proteinous Non proteinous Gelatins • Haemaccel • Gelofusin Albumin 20% & 5% Starch Dextrans  HES  PentaStarch  Tetrastarch
  12. 12. CRYSTALLOIDS • Crystalloid are electrolyte solutions with small molecules that can diffuse freely from intravascular to interstitial fluid compartments. • The principal component of crystalloid fluids is sodium chloride.
  13. 13. CRYSTALLOIDS HYPOTONIC ISOTONIC HYPERTONIC IONIC NON-IONIC • D5W • ½ NS(0.45%) • NS • RL • Plasmalyte • Hypertonic saline • 10%, 25% & 50% dextrose. • NS • Dextrose saline (DNS) • Ringer’s lactate • 5% Dextrose • 25% Dextrose
  14. 14. NORMAL SALINE • One of the most commonly administered crystalloids • Composition • Na-154 meq/l • Cl- 154 meq/l • pH- 5.7 • hence it affects the acid base balance of the body • Pharmacological basis 1. Provide major extracellular electrolytes. 2. Corrects both water and electrolyte deficit. 3. Increase the intravascular volume substantially.
  15. 15. Indications • To maintain effective blood volume and blood pressure in emergencies • Water and salt depletion – diarrhea, vomiting, excessive diuresis or excessive perspiration • Hypovolemic shock- distributed in extracellular space expanding the intravascular volume. Ideal fluid to increase blood pressure. • Preferred in case of brain injury, hypochloremia metabolic alkalosis , hyponatremia • Initial fluid therapy in DKA
  16. 16. • In patients with hyperkalemia like renal failure • Hypercalcemia • Fluid challenge in prerenalARF • Irrigation for washing of body fluids • Vehicle for certain drugs
  17. 17. Contraindications • Avoid in Hypertension, Preeclampsia and in patient with edema due to CCF, renal failure and cirrhosis • In dehydration with severe hypokalemia – deficit of intracellular potassium because of infusion of NS without additional K+ supplementation can aggravate electrolyte imbalance • Large volumes or too rapid administration can cause sodium accumulation and pulmonary edema. • Increased chloride content in relation to plasma can cause hyperchloremic • metabolic acidosis in large volume administration
  18. 18. RINGER’S FLUIDS • A solution that contained calcium and potassium in sodium chloride solution to promote cardiac contraction and cell viability. • Ringer`s lactate is the most physiological fluid as the electrolyte content is similar to that of plasma . • Larger volumes can be infused without the risk of electrolyte imbalance • Due to high Na ( 130mEq/L) content RL rapidly expands intravascular volume effective in treatment of hypovolemia.
  19. 19. • Composition • Sodium:131meq/l • Potassium – 5meq/L • Bicarbonate – 29 meq/L • Chloride – 111meq/L • Calcium – 2meq/L • Each 100 ml contains • sodium lactate - 320mg • NaCl - 600mg, • KCl- 40mg • CaCl- 27mg
  20. 20. Indications • Correction in severe hypovolemia • Replacing fluid in post operative patients, burns , fractures. • Diarrhea induced hypokalemic metabolic acidosis and hypovolemia. • Fluid of choice in diarrhea induced dehydration in pediatric patients. • In DKA,provides glucose free water, correct metabolic acidosis and supplies potassium • Maintenance fluid during surgery
  21. 21. Contraindications • Severe liver disease, severe hypoxia , shock – impaired lactate metabolism –lactic acidosis. • Severe CHF - lactic acidosis takes place. • Addison’s disease • In vomiting or continuous nasogastric aspiration, hypovolemia is associated with metabolic alkalosis - as RL provides HCO3- Worsens alkalosis. • Simultaneous infusion of RL and blood- inactivation of anticoagulant by binding with calcium in RL – clots in donor blood. • Certain drugs – amphotericin, thiopental, ampicillin, doxycycline should not be mixed with RL – calcium binds with these drugs and reduces bioavailability and efficiency
  22. 22. DEXTROSE SOLUTIONS • D5 water (5%D) • Dextrose with 0.9% NS ( DNS ). • Dextrose with 0.45% NS (D 1/2NS ) • 10% dextrose • 25% dextrose • EFFECT OF DEXTROSE IN FLUID :  Protein sparing effects  Volume effect  Lactate production.  Effect of hyperglycemia
  23. 23. Protein sparing effect • Earlier it was used to provide calories in patients who were unable to eat • 50 grams of dextrose per liter provides 170 kcal • Infusion of 3 liters of a D5 solution daily (125 mL/min) provides 3 x 170 = 510 kcal/day, which is enough nonprotein calories to limit the breakdown of endogenous proteins to provide calories (i.e., protein- sparing effect)
  24. 24. Volume Effects 5%D • 50 g of dextrose adds 278 mOsm/L to IV fluids • For a 5% dextrose the added dextrose brings the osmolality close to that of plasma. • However, dextrose is taken up by cells and metabolized, this osmolality effect rapidly wanes, and the added water then moves into cells. • The infusion of one liter of 5D results in an increase in ECF (plasma plus interstitial fluid) of about 350 mL, which means the remaining 650 ml (two- thirds of the infused volume) has moved intracellularly. • Therefore, the predominant effect of D5W is cellular swelling.
  25. 25. DNS • Total osmolality of DNS fluid is 560 mOsm/L (278 of dextrose and 308 0f 0.9 NaCl) which is almost twice the normal osmolality of the extracellular fluid. • If glucose utilization is impaired (as is common in critically ill patients), large-volume infusions of D5W can result in cellular dehydration
  26. 26. Enhanced lactate production • In healthy individuals 5% of infused glucose is directed towards lactate formation. • In critically ill patients 85% of glucose is diverted to lactate production. • when circulatory flow is compromised, infusion of 5% dextrose solutions can result in lactic • acid production and significant elevations of serum lactate
  27. 27. Hyperglycemia It has several deleterious effects in critically ill patients including –  immune suppression .  increased risk of infection  aggravation of ischemic brain injury Considering the high risk of hyperglycemia in ICU patients, and the numerous adverse consequences of hyperglycemia, infusion of dextrose containing fluids should be avoided whenever possible.
  28. 28. 5 % DEXTROSE Composition : Glucose 50 gms/L + free water Pharmacological Basis •Corrects Dehydration And Supplies Energy ( 70kcal/L) •Administered safely at the rate of 0.5gm/kg/hr. without causing glycosuria Metabolism  Dextrose is metabolized leaving free water distributed in all compartments of the body.  A proportion of dextrose load contributes to lactate formation –  5% in healthy subjects  85% in critically ill patients  hence not the preferred fluid.
  29. 29. Indications of 5%D • Prevention and treatment of intracellular dehydration • Cheapest fluid to provide adequate calories to body • For pre and post operative fluid management • IV administration of various drugs • Treatment and Prevention of ketosis in starvation, vomiting, diarrhea • Adequate glucose infusion protects liver against toxic substances. • Correction of hypernatremia due to pure water loss ( Diabetes insipidus)
  30. 30. Contra indication 1. Neurosurgical procedures - can aggravate Cerebral oedema and increase ICT 2. Acute ischemic stroke- • hyperglycemia aggravates cerebral ischemic brain damage. • Dextrose metabolism aggravates tissue acidosis in ischemic areas- anerobic oxidation of glucose produces more lactic acid and free radicals 3. Hypovolemic shock • Poor expansion of intracellular volume. • Faster rate of infusion causes osmotic diuresis  worsens shock and false impression of the hydration status  reduced fluid replacement. 4. Hyponatremia & water intoxication - 5%D worsens both conditions
  31. 31. 5.Hypernatremia – fast infusion of 5D rapidly corrects hypernatremia but correction occurs slowly in brain cells, so swelling of brain cells can lead to permanent neurological damage. Moreover rapid infusion of 5D induces osmotic diuresis which aggravates hypernatremia 6. Can cause Hypokalemia, hypomagnesemia and hypophosphatemia 7. Bloodand dextrose solutions should not be administered in same IV line – hemolysis , clumping seen due to hypotonicity of the solution. 8. Uncontrolled DM , severe hyperglycemia
  32. 32. DEXTROSE SALINE (DNS) Composition • Na- 154 mEq/L CI- 154mEq/L • Glucose- 50 gm/L Pharmacological basis • supply major extracellular electrolytes, energy and fluid to correct dehydration • In presence of incompletely or partially corrected shock patient will have increased urine output (due to diuresis) • Unlike 5D, DNS is not hypotonic (due to Nacl) and hence it is compatible with blood transfusion
  33. 33. Indications • Conditionswith salt depletion and hypovolemia not the ideal fluid though. • Faster rate of infusion causes osmotic diuresis. worsens shock and false. • impression of the hydration status reduced fluid replacement • Correctionof vomiting or nasogastricaspiration induced alkalosis and hypochloremia along with supply of calories
  34. 34. contra indication • Anasarca – cardiac, hepatic or renal cause • Severe hypovolemic shock – rapid correction is needed. Faster infusion can cause osmotic diuresis and worsen the condition.
  35. 35. DEXTROSE WITH HALF STRENGTH SALINE •Composition : 5% dextrose with 0.45% NS NaCl – 77 meq/L each, glucose 50 gm/L • Contains 50% salt as compared to DNS /NS and used when there is need for calories , more water and less salt. •Indications 1. Fluid therapy in pediatric – In pediatric group ratio of requirement of water : NaCl is double as compared to adults 2. Treatment of severe hypernatremia It corrects hypernatremia gently, it avoids cerebral edema 3. Maintenance fluid therapy and in early post operative period. •Contra indication 4. Hyponatremia 5. Severe dehydration where larger salt replacement is needed
  36. 36. 10%DEXTROSE &25% DEXTROSE Composition Pharmacological basis: • It is hypertonic crystalloid fluid • Supplies energy and prevents catabolism useful when faster replacement of glucose is • needed like in Hypoglycemic coma • In patients with fluid restriction- CCF, Cirrhosis and Renal failure
  37. 37. Indications • Rapid correction of hypoglycemia . • In liver disease, if given as first drip, it inhibits glycogenolysis and gluconeogenesis • Nutrition to patients on maintenance fluid therapy. • Treatment of hyperkalemia with Insulin
  38. 38. Contra indication • In patients with dehydration, anuria, intracranial hemorrhage and in delirium tremens. • Avoided in patients with diabetes unless there is hypoglycemia. • Rapid infusion of 25D can cause glycosuria. • Hence the absence of in hypoglycemia it should be infused slowly over 45 - 60 min. •