Fluid

 Total body weigh percentage- 60% (Adult)

Infant- 80%

Older client- 45%

Types of fluid compartment

1.Extracellular- It makes 1/3rd 

2.Intracelluar- It makes 2/3rd part.

1.Extracelluar- It contains-

-Interstitial fluid compartment.

-Intravascular fluid compartment.

-Small fluid compartment.

1.Solute-Substance that is dissolved

2.Solvent- Solution in which the solute is dissolved

Forces- (Body fluid transport)

1.Diffusion- Is the process to movement of solute from high concentration to low concentration through the semi-permeable membrane. 

2.Osmosis- Drawn of solvent from less concentration of solute to high concentration of solute through semi permeable membrane. 

3.Filtration- Movement of solute and solvent by hydrostatic pressure. 

4.Hydrostatic Pressure- It’s type of force exerted by the weight of solution.

-At arterial end- H.S.P.-O.P.- fluid and solute moves out of the capillary.

-At venous and- O.P.-H.S.P.-fluid and solute move into the capillary. 

Isotonic Solution- 

When the solution of both side of a compartment (separated by semi-permeable) are equal in concentration.

⦁ Little Osmosis occur-

When it is adm. to body.

⦁ increase E.C.F. volume.

Hypotonic Solution-

        Lower concentration of solute and high concentration of solution than isotonic. 

⦁ Less salt and more water.

⦁ Less osmolarity.

⦁ Movement of water into cells by osmosis.

⦁ Cellular edema.

Hypertonic solution-

          Higher concentration of solute less concentration of solution. 

⦁ causes cellular shrinkage 

 I.V Fluid

Istonic :- Solute = Solvent

Hypontonic – Solute decreased        Solvent decresed 

                          Celluar edema

Hypertonic – Solute increased         Solvent decreased 

                         Cellular    Shrinkage

1.Isotonic –

⦁ Solute  Solvent

⦁ 0.9 % NS

⦁ RL solution / Hartman solution

⦁ Extracelluar fluid increased

⦁ 5% Detrose in water [ DsW]

⦁ 5% Dextrose in 0.225 % NS [ ¼ NS]

2. Hypotonic –

⦁ Solute    ed

⦁ Solvent    ed

⦁ 0.45% NS [ ½ Ns]

⦁ 0.225%NS[1/4 NS]

⦁ 0.33% NS [1/3 NS]

Cellular edema

Solute     ed                  Solvent     ed 

3. Hypertonic –

⦁ 3% NS

⦁ 5% NS

⦁ Cellular shrinkage 

⦁ 5%  in 0.9 % NS

⦁ 5% Dextrose in RL

3. I.V fluid site :- 

⦁ Infant – Scalp, Feet

⦁ Adult – anticubitol fossa       

I.V fluid complication

1. Infilteration :- Seepage of fluid out of the vein in the surrounding spaces .

                              C/S –  *Coolness at the site 

                                         *Edema 

                                         *Pallor

                                         *I.V fluid adm. sluggish

                          Prevention :- [ check the I.V tubing for blood ]

⦁ Lower the I.V fluid container below the I.V site and monitor the appearance of blood in the TV tubing 

⦁ If blood appear it means I.V device is in the veinand start the infusion.

Intervention :-

⦁ Stop the infusion

⦁ Remove the IV device immediately & restart in another extermities and elevate the related extremity above the heart level to decreased the edema.

2. Phlebitis :- Inflammation of vein 

          * Thrombophlebitis – Throbus association C inflammation

         * Phlebothrombus – Thrombus association C out inflammation .

Q. K infusion से कौनसा complication  होता है

Ans. Phlebitis.

C/S-  

⦁ Het at infusion site.

⦁ Redness

⦁ Iv fluid slugyish

Two type 

⦁ Mechanical- Iv canul lower than /smaller the vein

⦁ Chemical-using irritation solution(K).

Prevention –

⦁ Avoid using the irritating solution.

Intervention- 

⦁ Stop the infusion.

⦁ Restore in another extremity.

3.Air embolism- (Bolus of air enter into the vein)

C/S- 

⦁ Pericardial region crackle sound on auscultation.

⦁ Tachycardia 

⦁ Charhing sound.

⦁ Dydspnoea 

⦁ Hypotension

Prevention – 

Prevent air entry in the tubing .

Intervention-

⦁ Left side-line position come with tredlenberg position to trap the emboli in the night atrium.

⦁ Notify the physician .

4.Fluid overloaded condition /Circulatory overloaded condition/ hypervolemia condition/ over hydration- 

Pulse-Bounding pulse(+4)

Cause- Administer to rapidly infusion 

Prevention-Continuous monitoring 

C/s-

⦁ Distended juglar vein.

⦁ Hypervolemia, weight gain 

⦁ Hypertension.

⦁ Tachycardia

⦁ Tachypnea

⦁ Dyspnea –oedema-pulmonary edema.

Intervention-

⦁ Slow the infection

⦁ Given up-right position

⦁ Notify physician

⦁ Diuretics

Infection-

Micro-organism- puncture site-localized infection

        Blood-systemic infection

C/S-

⦁ Drainage at the site ,red temp,

⦁ Chills& rigor, increase W.B.C.

Intervention-

⦁ Notify the physician

⦁ Sampling/ laboratory test- Antibiotic.

[जब भी K चढ़ायेगे तो उस पर red sticker लगाकर रखना/Eg- RL]

⦁ Cannula को Sterile container  में रखना  laboratory में भेजना

⦁ Antibiotic.

Catheter Embolism-

C/S-

⦁ Decreased blood pressure

⦁ Pain along the vein.

⦁ Weak pulse cyanosis condition at nail be

Intervention-

1.Tourniquit-the R/T extremity in distal part .

2. Obtain x-ray

3.Vein suction cut down 

“Blood”

 Blood 8% of body weight.

                                                                Blood

55% plasma protein        45% other formed elements 

1.Protein(1%)         Water         Other solution       1.RBC-   Erythropoltetic drugs

2. Albumin(54%)        (91-92%) (2%)like           epoetin-Alpha

3.Globulin(38%) Zn, iron                                 Darbe portein –Alpha 

4.Fibrinogen(4%) .                                                        Heucopoieteic  drug

5.Prothrombin (1%)                                                                 2.W.B.C- Filgrastim

        -  Pegfilgrastim 

      3.Platelets-operlwakin

Clotting factors

⦁ Those substance  necessary for clotting are called clotting factors. These are- 

Factor 1-  Fibrinoge

Factor 2- Prothrombin 

Factor 3- Thromboplastin 

Factor 4-  Calcium

Factor 5- Labile  factor

Factor 6- Presence has not been proved

Factor 7- Stable factor

Factor8- Anti hemophilic factor

Factor 9- Christmas factor

Factor 10- Stuart prower  factor 

Factor11-  Plasma thromboplastin Antecedent

Factor 12- Hegman  factor

Factor- Fibrin stabilizing factor

ABO BLOOD GROUPS

-Landsteiner law के अनुसार RBC  की सतह पर उपस्थ्ति Antigen  or  agglutinogen के आदर पर  people को  4प्रकार के blood group  में बांटा गया है

- Blood group “A” - वह  person जिनकी RBC की  surface पर Antigen “A”उपस्थित होती है

- Blood group “B”- वह  person जिनकी RBC की  surface पर Antigen “B” उपस्थित होती है

Blood group “AB”- वह  person जिनकी RBC की  surface पर  Antigen “A” & Antigen “B” उपस्थित होती है

Blood group “O” - वह  person जिनकी RBC की  surface पर  Antigen “A” & Antigen “B” अनुपस्थित होती है

यदि किसी person की RBC की surface पर कोई Antigen   उपस्थित है तो उस person के plasma  में उस Antigen की Reciprocal  antibody उपस्थित होती है 

E.g. – Blood group “A” वाले person के plasma में Beta antibody 

Blood Transfusion Complication- 

⦁ Iron overloaded (haemosiderosis)          Excessive iron deposition

⦁ Delayed type complication 

⦁ Cause-Caused by massive b/d transfusion and totally dependent on b/d transfusion.

⦁ S/S-

⦁ Vomiting

⦁ Diarrhea

⦁ Hypotension 

Treatment- DOC-(Deferoxamine)

⦁ Urine color turn into –red ,organ,brown.

Intervention- Document finding.

⦁ Hypocalcemia-

⦁ ACD (Acid citrate dextrose) cantaing blood

⦁ Citrate +Ca+ Urine excretion increased

Hypocalcemia

C/S-

⦁ Cherosteks Sign- facial muscle पर  tapping करने पर muscle/ particular part (face)  एक तरफ खींच जाना 

⦁ Trosseau’s sign-B.p. cuff बांधने  के बाद 3rd inflation के time बाद sudden related extremity की  finger का tetanic condition  में  हो  जाना

⦁ Tetanic condition- muscle spasm.

⦁ ECG- ST &QT  interval का prolong  हो  जाना

⦁ Disease transmission- 

⦁ HIV

⦁ Hepatitis B

⦁ Hepatitis C

⦁ Septicemia-

Micro-organism-puncture site-locatized

                             Systemic septicemia (increase temp.)then notify the physician

S/S-

⦁ increased temp.

⦁ Chills, rigor, redness

⦁ Drainage at the site

⦁ Hypotension

⦁ Collapsed-death 

⦁ Hyperkalemia-

⦁ Prolonged storage b/d K cause-cardiac dysrhythmia, acidosis 

⦁ 21 days-35 days              K= 3.5 to 5.meq/L 

⦁ K+RBC Hemolysis

E.C.G.-

⦁ Flat P-wave

⦁ Widened QRS-complex

⦁ Peaked T-wave

⦁ Prolonged PR- interval

D.O.C.-

⦁ Kaxylabe

⦁ NaHco3 –To treat Acidosis

⦁ Ca-gluconate-to treat cardiac irritability BT rate=40 drop/min

⦁ Insulin In 21 storageK=23 mg/l

In  1 day storage K=7 mg/l

⦁ Transfusion Reaction-

⦁ Close observation- 

⦁ 15 min(first) Transfusion Reaction के ज्यादा chances

⦁ First50 ml blood 

S/S- 

⦁ Chest pain 

⦁ Dyspnea

⦁ Back pain

⦁ Itching

⦁ Fever

Prevention-

⦁ In cond of yes(transfusion reaction)

Premedicated treat with

Diphenhydramine & acetaminophen

Orally- befor B/t -20-30 min administer

IV- before B/t -5min

Intervention-

⦁ Stop the transfusion immediately

⦁ N.S. to admit emergency drug +drugs

⦁ Notify the physician 

 Type of Blood component 

⦁ Packed RBC- 

⦁ RBC admit

⦁ 1 unit RBC-19/dl-Hb increased (4-6 hrs 

⦁ 2-4% haematocrit value increased (% of RBc mass)

Use- CRF- Erythropotein Anaemia 

⦁ Platlets- 1 unit=50-70 ml

⦁ It is used to trest thrombocytopenia

⦁ During adin cross matching well not required (Ag(-)nt)EG- Dengue fever

⦁ F.F.P.- (fresh frozen plasma)-

⦁ It is used to treat the fluid volume expension. 1. Unit=250 ml

⦁ It protein clotting factor (Hcl)

⦁ It’s cantain no platletes. 

Uses- Shock condition.

⦁ Cryoprecipitate-

⦁ It derived from ffp

⦁ It provide 8th & 1-clotting factor 

⦁ Packed –WBC-

It is used to treat neutropenia condition.

Blood Group-

               A          B     AB      O

        A O      B          O         A        B             O          O

Q. Father Blood Group A Mother Blood group AB

                   A                                AB

        A               O                   A           B

AA            AB                      AO                           BO

Generation- A,AB,B.

Pareneteral nutrition

Enteral Nutrition-GI tract capable होता है  और food  को tube (ryle’s tube) के through  feeding करवाई जाती है by orally.

Parenteral nutrition- GI tract not capable and admit the fluid by veins.

Type- 

1.Total P.N. (TPN)-10% increased glucose contain.

2. Peripheral P.N.

1. TPN-  Tpn contain 10 % above glucose contain cepend on duration- admin in two ways

A) Short period- shorter than 4 week.

B) Long period-longer than 4 week upto 6 months.

A) shorter duration-

Site- Subclovian vein Done by central venous catheter

     Internal juglar vein

B) Long duration 

Site- PICC(peripheral inserted center catheter) anticubital fossa (Basilic vein, cephalic vein)

                         To prevent air embolism

⦁ PICC used mostly to prevent air embolism .in condition of change tubing client should be turn on it sideline position come with tredelenberg position and turn the head in opposite the site of inserton –to prevent 

Mixture of P.N.

Carbohydrate     Dextose(simplest)

Protein A.A.

Lipid Emulisidside Fate 

Filter use- 

⦁ 0.22 Hm-2 in 1 solution (dex+A.A)

⦁ 1.2 hm- emulsiside fat

⦁ T.p.n. Indication C/S- temp, wt gain,

Complication of PN-

⦁ Circulation overloaded condition- Refeeding syndrome 10% से ज्यादा glucose देना refeeding  होता है 

⦁ Air embolism

⦁ Hypoglycemia abruptly close TPN

⦁ Hyperglycemia-High conc.of glucose

⦁ Admin insulin heparin (Keep insulin& hepair near bedside)

⦁ Hyperglycemia- 

C/S- Kussmat’s respiration(Rate & depth increase)

Cause-it is caused by the admin of high conc. Of glucose or admibnistered two quickly the P.N. salution.

S/S- Kussmalu’s respiration

           3P’s –excessive thrist

Increased blood glucose level (200 mg/dl

Late sign- Confusion& Coma 

Intervention 

⦁ Administer insulin

⦁ Continue monitor the blood glucose level.

⦁ Notify the physician

⦁ Hypoglycemia-

⦁ Mild below 60mg/dl

⦁ Moderate below 40 mg/dl

⦁ Sevee 20 mg/dl-unconscious.

⦁ Administer glucogon Im (priority Nsg intervention)

Cause- It is caused by the abruptly cessation /close the P.N. solution or

Excessive administer of insulin.

S/S- Low blood glucose level      insulin 

      Shakyness   Glucose Glucogen  

       Hunger Glucogen

      Weakness

Prevention-Gradully decrease the PN solution thn discontinued

Intervenntion- Adm. 5-10 % dextrose in same rate to prevent hypoglycemia.

⦁ Pneunothorax (accumulation of abnormal air in pleural cavity)

Intervention- Closed chest tube drainage sys/ water seal drainage system.

Cause- catheter tip touch the pleural cavity.

Prevention- After catheterization x-ray to canfirm the tube, insertion,

 

Special constaeration related with administration of IV, blood  parenteral nutrition administration.

Blood Transfusion-

⦁ Never to be infused large amount of refrigerated blood.

⦁ Because it cause cardiac dysrhythmia

⦁ No solution other than NS should be added 

⦁ Never to be added medication during the blood transfusion

⦁ Decreased the risk of septicemia.1 unit blood should not be exceeds greater then 4-6 hrs (Max time=4 hrs.;

⦁ BT-set should be chandged after 1 unit.

⦁ Blood को refrigeratorसे बहार निकालने  पर 20-30 min wait  करते है

⦁ Blood should be infuse with in 20-30 min in case of delay send back to the laboratory.

⦁ Before & after BT vital sign checked (To identify infection).

⦁ Given Close monitoring first 15 min and first 50 ml blood volume administration .

⦁ BT Conformatiuon is presence of 

⦁ In case of any type of transfusion reaction premedication treat  with diphenhydramine and acetaminophen.

IV administration-

⦁ Hand washing should be done before and after the procedure and wearing a gloves.

⦁ Change the vein puncture site every 48-72 hr.

⦁ Change the iv dressing every 72 hrs. Exception-if dressing become wet it should be changed immediated to prevent the risk of infection.

⦁ Change the iv tubing every 24-72 hr.

⦁ Do ot allow the iv tubing touch to the floor .becouse it cause bacteriqal contaminatiuon

⦁ Iv solution को every 24 hrsमें  change कर देंगे

⦁ Commonest site-

Adult- anticuboital fossa, forearm

         Child-Scalp, feet

⦁ Never to administer the IV fluid in the thigh of adult to prevent the risk of DVT (c/s-Human’s sign)

⦁ Drip chamber- two type –

Macro chamber

Micro chamber

      Macro chamber- it is used when solution become thick and infuse rapidly.

      Micro chamber-it is used when infusion rate become <50 ml/hr.

       Drop factor-60 gtt/ml

P.N. administration –

⦁ Carbohydrate- in the from of dextrose upto 70% calorie provide

⦁ Amino acid-it is form of protein. It provide 5-20% energy.

⦁ Fat- in the form of emulisified fat . given energy upto 30%.

⦁ Before administer of emulisified lipid- Allergic testing should be done because it contain ,Egg, yolk& soyabean 

⦁ Infusion Rate of emulsified Fat- infusion rate should be 1 ml/min and check vital sign first 10-15 min.

⦁ Given closely monitoring for adverse reaction. First 30 minute, 

Sign of adverse reaction- 

⦁ Chest pain 

⦁ Diaphoresis( excessive sweating) 

⦁ Dyspnoea

⦁ Cyanosis

⦁ Headache.

Sign of over hydration& dehydration-

Overhydration                                Dehydration

1.Bounding pulse(+4)   1. Weak & thread pulse(+1,+2)

2.HR increase           2. B.P. –decreased (orthostatic hypotension 

3. Blood volume-increase   or postural hypotension )

4. B.P. increase   3. Flat neck veins

5. Distended juglar vein.   4. Diminished peripheral pulse

6. Increase respiratory rate   5. Decreased urine-output& increased urine 

(Tachypnoea)            specific gravity

7.Dyspnoea   6. Increased hematocrit value

8.Crackle sound is present on   7. Increased BUN level 

Auscultation   8. Decreased body weight

9.Diarrhoea (Gimotility increase- 9. Dry skin (ageing cause) (old client -45%

Increase peristaltic movement    infant-85%) 

10 Ascites 

11. Decrease Hematocrit value

12. Decreased Bun Level

13,Weight gain(c/s of TPN 

Progress)

⦁ Malaria patient not transfer blood till 5 year

⦁ HIV, Hep-B infected patient through out life not transfuse the blood.

I.V. gauges- gauge related with the diameter of lumen of needle and cannula.

Small gauge number larger diameter of lumen- 

Allow higher fluid rate

Larger gauge number smaller the diameter of lumen allows higher concentration of solution. 

Filter- It is used prevent the entry of particles into the veins of the client.  

- 0.22 um

- 1.2 um

I.V. Tubing-

Parts-1 spike and for I.V. bottle

2. Drip Chamber.

3. Roller Clamp

4. Adapter and of tubing for needle. 

CARE OF DYING PATIENT / STANDERD NURSING

1. Palliative care- Used for serious life limiting illness.

- The goal of palliative care, the prevention, relief reduction or soothing of symptoms of disease or disorder without effective cure.

It (P.C.) is for any age, any diagnosis at any time and not just during the last month of life.

- Hospice case is an alternative for the terminally ill.

- It is one phase of palliative care.

Duration- Patient accepted into a hospice programme have less then- 6 month to live.

- It is not a facility but a concept for family centered care designed to assist the patient is being comfortable and maintaining a satisfactory lifestyle until death.

Components:

1. Patient and family as the unit of care.

2. Symptoms management.

3. Medical and Nursing services available at all times.

4. Approaches to case involves, physician, health care provides, nurses, social worker, professionals and pharmacist.

- Also provides alternative medicine approaches such as massage or music, art therapy.

NURSE – CLIENT RELATIONSHIP /  STANDARED NURSING 

1. Pre-interaction- This phase begins before the nurse’s initial contact with the client.

- Self-awareness is necessary task before one can establish maturity with others. 

- Additional task of this phase include gathering the more date about the client and planning for the first interaction with the client.

2. Orientation or introductory- The Nurse’ who’ once strange initially, establishing a trusting relationship with the client by making a good communication. 

3. Working phase- Nurse and client discuss the problem, help to plan, implement and evaluate a course of action.  

- Anxiety level may be rise, denying is expected resistance to change can be anticipated. 

- Problem should be discussed and resolved. 

4. Termination- It is the ending phase of nurse-client therapeutic relationship. 

- Summarized occur 

- Anger rejection, and other negative behavior may be expressed.  

 Legal Risk Area / Standard Nursing

⦁ Battery :- Battery is intentional touch of another body court consent .

⦁ Assault :- When a person put another person in fear ,harmful & “Offensive manner” 

⦁ False imprisonment :- When restrain device are used without appropriate clinical need .

⦁ Confidentiality :- Making a confidentially & do not share the client information with unauthorized person [ Rt. Of privacy ]

⦁ Defamation :-  It is a type of assault & false communication that causes damage to someone “respiration “ either in writing [libel] or verbally [Slander] 

Q.1 The best position for examining the rectum is – 

 (A) Prone        (B) Sim’s

 (C) Knee chest                    (D) Lithotomy

Ans - C

⦁ Gait – Manner of walking

⦁ Antiseptic – Inhibit the growth and development of m.o without killing them or agent applied to skin to eradicate pathogenic microbes.

⦁ Bactericidal – Power to kill the m.o

⦁ Bacteriostasis – Inhabit growth of bacteria 

⦁ Asepsis – Employment technique to achieve microbe- free environment 

⦁ Sepsis – Known or suspected infection in which body is in slammed.

⦁ Hydrostatic pressure :- Pressure caused by water volume in the resells.

⦁ Bruise :- An injury that discolors but does not break the skin.

⦁ Xerostomia :- Dry mouth

⦁ Purities – Itching 

⦁ Normocytic – Normal size of RBC

⦁ Incubation  period of Rabies - Depend on site of bite

⦁ Bacteria cause Diptheria is known as –

             Ans- Klebs – Loffler bacillus /Corny bacteria diphtheria.

⦁ Subjective data – Covert

⦁ Objective data – Overt

⦁ Flip over card – Kardex

⦁ The degree of patient’s abdominal distension may be determined by –

⦁ Auscultation (B) Palpation 

        (C)Inspection (D) Percussion