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“ Be a doer not a me too-er.”
Dr. Greg House
All liquids taken by the patient
Oral fluids Water, milk, juice, soft drinks, coffee, tea, cream, soup, sherry, wine
Water taken with medications
Ice chips – approximately ½ their volume
Foods that become liquid at room temperature
Ice cream, sherbert, custard, gelatin, pudding, popsicle
soup, & broth, ice water, frozen yogurt
A full cup of ice is equal to 1/2 cup of water (120cc).
Note: do not measure foods that are pureed; these are solid food prepared in a different form
Tube feedings Remember to include the 30-60 ml. water rinse at the end of intermittent/ continuous feedings
Parenteral fluids IVF, blood & its components
Total Parenteral Nutrition (TPN)
A patient has recorded the following on a sheet of paper at the bedside:
Breakfast: eggs, toast, one cup of coffee (coffee cups at this hospital contains 6 ounces); small orange juice (4 ounces)
Lunch: sandwich, apple, glass of tea (glasses at this hospital contains 8 ounces)
Dinner: chicken, broccoli, rice, 2 glasses of tea
Between meals: 4 glasses of water 1000 mL of D5 W infusing IV at
30 mL/hour
Calculate the Intake for a 12 hour shift: Note you need to covert ounces to mls.
Dextrose in Dextrose in H2O SolutionH2O Solution
Other NameOther Name ConcentratioConcentrationn
Dextrose 5 Dextrose 5 % in water % in water
D5WD5W IsotonicIsotonic
Dextrose 10 Dextrose 10 % in water% in water
D10WD10W HypertonicHypertonic
Saline Saline solutionsolution
Other NameOther Name ConcentratioConcentrationn
0.45 % NaCl 0.45 % NaCl (Half NS)(Half NS)
½ NS½ NS HypotonicHypotonic
0.9 NaCl0.9 NaCl NSNS IsotonicIsotonic
3-5% Sodium 3-5% Sodium ChlorideChloride
3-5 % NS3-5 % NS HypertonicHypertonic
3-5% NaCl3-5% NaCl
Dextrose in Dextrose in Saline Saline SolutionSolution
Other NameOther Name ConcentratioConcentrationn
Dextrose 5% Dextrose 5% in .9 NaClin .9 NaCl
D5 0.9% NaClD5 0.9% NaCl HypertonicHypertonic
D5 0.9% NSD5 0.9% NS
D5NSD5NS
Dextrose 5% Dextrose 5% in .45% NaClin .45% NaCl
D5 0.45% D5 0.45% NaClNaCl
HypertonicHypertonic
D5 0.45% NSD5 0.45% NS
D5 1/2 NSD5 1/2 NS
Multiple Multiple Electrolyte Electrolyte SolutionsSolutions
Other NameOther Name ConcentratioConcentrationn
Lactated Lactated Ringers Ringers SolutionSolution
LRLR IsotonicIsotonic
Dextrose 5% Dextrose 5% in Lactated in Lactated Ringers Ringers SolutionSolution
D5LRD5LR HypertonicHypertonic
Isotonic Solution – extracellular volume replacement; FVD secondary to excessive vomiting
Intravenous medications
IV medications that are prepared with solutions (ex. NSS)
Ex. Tobramycin sulfate 80 mg. in 50 ml.
Catheter or tube irrigants
Fluid used to irrigate urinary catheters, NGT,
intestinal tubes
Urinary outputAfter each voiding, pour the urine in a measuring container,
Observe the amount &
and record it & the time of voiding on the bedside I & O form
Retention catheter – note & record the amount of urine at the end of the shift then empty the drainage bag.
If the client is incontinent of urine or is extremely diaphoretic, estimate and record these outputs
“Incontinent X 3” or “Drawsheet soaked in 12 inches diameter.”
Weigh diapers or incontinent pads that are dry, then subtracting this weight from the weight of soiled items.
1 gram = 1 ml. of urine
If the urine is frequently soiled with feces, record the number of voiding instead.
Vomitus & liquid feces
Time & type of fluid must be specified
Diaphoresis Record “Perspiring profusely.” or Perspiration ++++
Check agency policy on this
Tube drainageGastric, intestinal drainage
Wound drainage & draining fistulas
Recorded by counting the type & number of dressings; linen saturated with drainage
Measuring the exact amount of drainage collected in a vacuum drainage system
( Hemovac, Jackson Pratt drain )
Amount of input & output must be measured in 24 hrs.
Recorded in I & O sheet
Input & Output must be recorded at the end of every nursing shift
Nursing procedure
obtaining an accurate data base
evaluating client’s hydration status
Following a surgical procedure
Febrile clientsClients with fluid restrictions
Client under diuretics/IVF therapy
Chronic CP/Renal Illness
Unstable Client
The patient recorded the following amounts voided on the sheet of paper: 400 cc at 7:00 am; 100cc at 10:00 am; 200cc at 12 noon; 150 cc at 2:00 pm; 400cc at 6:00 pm. The nurse emptied 300cc from a JP tube. The patient vomited 100cc at 4:00 pm What is the total output for the 12 hour shift?
Laboratory StudiesSerum/Urinary electrolyte levels
Hematocrit (Hct)
CreatinineBlood Urea Nitrogen (BUN)
Urine Specific Gravity
5 % weight gain – moderate FVE
EyesSunken, dry conjunctivae,
Decreased tearing - FVD
Periorbital edema, papilledema – FVE
Throat & MouthDry mucous membrane,Dry cracked lips, decreased salivation - FVD
CV SystemFlat neck veins, slow venous filling – FVD
Distended neck veins - FVE
Increase PR, weak pulse, low BP – FVD
Bounding pulse, 3rd heart sound, hypertension - FVE
Respiratory SystemCrackles, increase RR – FVE
GI SystemSunken abdomen – FVDDistended abdomen – 3rd space syndrome
Renal systemOliguria/Anuria – FVDEdema (dependent areas-sacrum, back, legs - FVE
SkinDecreased body temperature, dry frosted skin, cold clammy skin, inelastic skin turgor - FVD
single most important indicator of fluid status
Must be done:1.Same time each day2.Same scale after the
client voids
3.Client must wear same clothes
4. If bed scale is used, must have same number of sheaths
If client is under fluid restrictions, allowed to take 30 ml. of water
Allow half of the allotted oral fluids between 7 am - 3 pm.
Why ?
Client is most active at that time
Received 2 mealsTake most of their oral medications
Urine is liquid waste product of the body secreted by the kidneys by a process of filtration from blood and excreted through the urethra.
Change in urine volume – significant indicator of fluid alterations or kidney disease
Plastic receptaclesUrinalsbedpans
Urimeter can hold 100-200 ml. of urine, after measuring can be drain into a receptacle or urine bag for disposal
To measure urine volume, use separate plastic graduated measuring receptacle
Normal Urine Output 30 cc./hr.1500 ml./day
Hourly urine output < 30 ml. for more than 2 hrs. is a cause for concern
< 0.5 ml/kg./hr. for 2 consecutive hrs
Daily urine output of 2000-2500 ml. daily-
Must be reported to the physician
Oliguria – small volume of urine
Urine output = 100-500 ml./24 hr
Anuria – absence of urine output
Output < 50 ml./24 hr.
To determine whether the fluid output is proportional to intake or there is a change in the client’s fluid status
The nurse compares the total 24 hr. fluid output measurement with the total fluid intake measurement
Compares both to previous measurements
Urinary output = Amount of fluids ingested
Urine output = 1500-2ooo ml. in 24 hrs.
or 40 – 80 ml. in 1 hr.
RouteRoute Gain Gain (ml.)(ml.)
RouteRoute Loss Loss (ml.)(ml.)
H2O H2O (food)(food)
10001000 SkinSkin 500500
H2O H2O (oxidation(oxidation))
300300 LungsLungs 300300
H2O H2O (liquid)(liquid)
12001200 FecesFeces 150150
KidneysKidneys 15001500
TotalTotal 25002500 == 25002500
Nursing Responsibilities:
1. No room for error in calculating dosages
2. Check math work with another nurse
3. Work problems systemically & carefully on paper
4. Recheck calculations
5. Is the answer reasonable?
Metric Apothecary 60 mgs 1 gr. 1000 mgs 15 gr. 4 grams. 1 dram 30 grams. 1 oz. .45 kg 1 lb. 1 kg. 2.2 lbs.
Formula when Preparing Solid or liquid forms
Dose Ordered X Amount on hand = Amount Dose on hand to
administer
Dose ordered – amount of medication prescribed
Dose on hand is the weight or volume available in units supplied by the pharmacy
Amount to administer – the actual amount of medication the nurse will administer;
expressed in the same unit as the amount on hand
Formula :Volume/Time x drop factor = drop rate
Volume/cc/hr = Time
The order reads : 1000 ml D5W to run for 8 hrs. Drop factor is 10.IV correctly set at 21 gtt./min. After 4 hrs. 500 ml. would be infused. However after 4 hrs. You find 600 ml. remaining. You must compute a new flow rate for 600 ml. to run for remaining 4 hrs.
If you are going to catch up the lost 100 ml. in 1 hr. can be very dangerous.
Do not do it!The flow rate must be
recalculated if the IV is off schedule.
Pediatric dosage refers to the determination of the correct amount,
frequency & the total # of doses of a medication to be administered to a child or infant.
Young’s Rule – 2 yr. old or older
Up to 12 years oldFried’s Rule – for infants less than 2 yrs. old
Clark’s Rule – uses child’s wt. to determine proper dosage
Estimating Body Surface Area – uses a nomogram
employs weight in determining the dose C.D. = Weight in lbs. X Adult dose
150
What is the dose of a drug for a 45 lb. child if the average adult dose of the medication is 15 mg ?
Child’s dose = 45 x 15 = 4.5 mg. 150
infants up to 2 years oldC.D. = Age in months x Adult
dose 150
What is the dose for a 9 month old infant If the average adult dose
is 35 mg?
Child’s dose = 9 x 35 = 2.1 mg 150
for children 2 years & older
C.D = Age (yr) x Adult dose
Age (yr) + 12
The adult dose of the drug is 7 grains. What is the dose of a 3 yr. old child?
Child’s dose = 3 x 7 gr. = 1.4 gr
3 + 12
finding the surface area in square meters (m2)
C.D. = BSA of Child (m2) x Adult dose
1.73 (m2) Average Adult B.S.A = 1.73 m2
ac – before mealsad lib – freely, as desiredbid – twice a dayc – withcap – capsuledil – dilute, dissolve
elix – elixirg, gm, Gm – gramgr – graingtt – droph – an hourhs – at bedtime (hour of sleep)IM – intramuscularIV – intravenouskg or Kg – kilogram
L,l – litermcg – microgrammg – milligramOD – right eyeOS – left eyeOU – both eyespc – after meals
po, PO – by mouthprn – when neededq – everyqAM – every morningqh – every hourqhs – every night at bedtimeqid – 4 times a day
qod – every other day Rx – take s – without Sc, sc, SQ – subcutaneous Sig or S – label stat – at once sup or supp – suppository tid – three times a day
60/M with obstructive jaundice due to a pancreatic head mass.
Prothrombin time is deranged. Patient will be needing Vitamin K.
I forgot what preparation of Vitamin K to give?
Is it Oral or Parenteral?Which is better?
Equipment:Syringes – consists of barrel, plunger & tip
Tuberculin syringe ( 1 ml.) – for small doses of epinephrine, intradermal skin tests & subQ meds
Measured in ml. long lines represent .1 ml.; shorter lines .05 ml. & shortest lines .01 ml.
3 ml. Syringe – most frequently used; for most IM injections; calibrated in ml. or cc.
Insulin syringe – calibrated in units; U 100 syringe holds 100 units/ 1 ml.; U 50 units/.05 ml.
Needles – hub, shaft & beveled tipNeedles – hub, shaft & beveled tip
Lumen – opening at the needles beveled end
Gauge – size of the diameter of the inside of the needle’s shaft; the smaller the gauge the larger the diameter of the needle
Needle length – selected based on the depth of the tissue into which the medication is to be injected
Intradermal injections – 3/8 - 5/8 inch
IM – 1-1 ½ inchSubQ – 5/8 – ½ inch
Needles should never be recapped to avoid needle stick injuries
Scoop technique
Formula when Preparing Solid or liquid forms
Dose Ordered X Amount on hand = Amount Dose on hand to administer
Example: The physician orders 15 mgs of diazepam (Valium). The nurse has Valium tablets that contain 5mg/tablet.
D/S x Q 15 mgs/5 mgs x 1 tab = 3
tablets
The physician orders 40 mgs of furosemide (Lasix). The nurse has an ampule of furosemide labeled Lasix 20 mg/ml.
D/S x Q 40 mg/20 mg x 1 ml. = 2 ml.
Formula :
Volume/Time x drop factor = drop rate
Volume/cc/hr = Time
Pediatric dosage refers to the determination of the correct amount, frequency & the total # of doses of a medication to be administered to a child or infant.
Young’s Rule – 2 yr. old or older
Up to 12 years old
Clark’s Rule – uses child’s wt. to determine proper dosage
Provide fluid & electrolyte maintenance, restoration & replacement
Administer medications & nutritional feedings
Administer blood & blood products
Administer chemotherapeutic drugs
Administer PCAKVO for quick access
Isotonic – exerts the same osmotic pressure as that of plasma
Normal saline 0.9%Lactated Ringers
Blood components (Albumin 5%, Plasma)
5% dextrose in water (D5W)
Hypotonic – exerts less osmotic pressure than that of blood plasma; forces water movement into cells to reestablish cellular equilibrium; cells expand or swell
Half-strength normal saline (0.45%)
One-third sodium chloride (0.3%)
Hypertonic – exerts higher osmotic pressure than that of plasma; draws water out of the cells into the extra cellular compartment to restore equilibrium; cells shrink
Dextrose 5% in normal saline 0.9%
Dextrose 5% in half-strength normal saline
Dextrose 10% in waterDextrose 20% in water
Saline 3% & 5%Hyperalimentation solutions
Dextrose 5% in lactated Ringer’s
Albumin 25%
Large –Volume Infusions – safest, easiest; medications are diluted in large volumes 500 ml. or 1000 ml. (Vitamins & KCl)
Intravenous bolus “Push” – introducing a concentrated dose of medication
directly into the systemic circulation; most dangerous method for administering medications; before administering a bolus the nurse confirms placement of the IV line.
Volume-Controlled Infusions – fluid within a secondary fluid container separate from the primary fluid bag.2nd container connects directly to the primary IV line.
Piggyback – a small IV bag or bottle connected to short tubing lines that connects to the upper y-port of a primary infusion line.
small bag or bottle is set higher than the primary infusion bag or bottle
Tandem – small IV bag or bottle connected to a short tubing line to the lower y-port of a primary infusion line.
Placed at the same height as the primary infusion bag or bottle
Tandem & mainline infuse simultaneously
Volume-Control Administration (Volutrol, Buretrol, Pediatrol, Solu-set) small containers (50-150 ml.) that attach just below the primary infusion bag or bottle.
Miniinfusion pumps – battery operated that allows medications to be given in very small amounts of fluid 95-60 ml.) within controlled infusion times using standard syringes.
Intermittent Venous Access (Heparin lock or Saline lock) – an IV catheter with a small chamber covered by a rubber diaphragm.
access must be flushed with a solution to keep it patent.