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The administration of a hydrating solution at a rate of 8 mL/m2 of body surface per minute for 45 minutes is called a fluid challenge menopause vomiting buy generic fosamax from india. If urinary flow is not restored after 45 minutes pregnancy belly band buy fosamax 35mg fast delivery, the rate of infusion should be reduced and monitoring of the patient should continue without administration of electrolyte additives menstrual after menopause buy fosamax 70mg online, especially potassium. Carbohydrates in hydrating solutions reduce the depletion of nitrogen and liver glycogen and are also useful in rehydrating cells. Potassium is essential to the body but can be toxic if the kidneys are not functioning effectively and therefore are unable to excrete the extra potassium. Combination solutions can be used by hypodermoclysis or subcutaneous route for hydration in clients with poor venous access. Balanced Electrolyte Solutions A variety of balanced electrolyte fluids are available commercially. Balanced fluids are available as hypotonic or isotonic maintenance and replacement solutions. Maintenance fluids approximate normal body electrolyte needs; replacement fluids contain one or more electrolytes in amounts higher than those found in normal body fluids. Balanced fluids also may contain lactate or acetate (yielding bicarbonate), which helps to combat acidosis and provides a truly "balanced solution. Special fluids available from manufacturers for gastric replacement provide the typical electrolytes lost by vomiting or gastric suction. These isotonic fluids usually contain ammonium ions, which are metabolized in the liver to hydrogen ions and urea, replacing hydrogen ions lost in gastric juices. This solution has some incompatibilities with medications, so it is necessary to check drug compatibility literature for guidelines. This solution is commonly used to replace fluid loss resulting from burns, bile, and diarrhea. At present, isotonic sodium chloride is recommended as the first-line fluid in resuscitation of hypovolemic trauma patients (Bulger & Maier, 2007). The lactate ion must be oxidized to carbon dioxide in the body before it can affect the acid­base balance. The isotonic solution sodium bicarbonate injection provides bicarbonate ions in clinical situations of excessive bicarbonate losses. Alkalizing fluids are used in treating vomiting, starvation, uncontrolled diabetes mellitus, acute infections, renal failure, and severe acidosis with severe hyperpnea (sodium bicarbonate injection). The 1/6 molar sodium lactate solution is useful whenever acidosis has resulted from sodium deficiency; however, it is contraindicated in patients suffering from lack of oxygen and in those with hepatic disease. The bicarbonate ion is released in the form of carbon dioxide through the lungs, leaving behind an excess of sodium. Acidifying fluids are used for severe metabolic alkalosis caused by a loss of gastric secretions or pyloric stenosis. However, a disadvantage is that ammonium chloride must be infused at a slow rate to enable the liver to metabolize the ammonium ion. In fact, rapid infusion can result in toxicity, causing irregular breathing and bradycardia. Ammonium chloride must be used with caution in patients with severe hepatic disease or renal failure and is contraindicated in any condition in which a high ammonium level is present. Replace fluid containers according to established organizational policies, procedures, and/or current practice guidelines. Flush vascular access devices prior to each infusion as part of the steps to assess catheter function and after each infusion to clear the infused medication from the catheter lumen to prevent contact between incompatible medications. Colloid Solutions Patients with fluid and electrolyte disturbances occasionally require treatment with colloids. Colloid solutions contain protein or starch molecules that remain distributed in the extracellular space and do not form a "true" solution. When colloid molecules are administered, they remain in the vascular space for several days in patients with normal capillary endothelia. These fluids increase the osmotic pressure within the plasma space, drawing fluid to increase intravascular volume. Colloid solutions do not dissolve and do not flow freely between fluid compartments. Infusion of a colloid solution increases intravascular colloid osmotic pressure (pressure of plasma proteins).

Catheter tip migration to the internal jugular vein has been associated with the "ear gurgling sign"; the patient complains of the sound of a running stream rushing past the ear women's health common issues cheap fosamax 70 mg with mastercard. Patient complains of headache or pain womens health 2 coffee generic fosamax 35mg, swelling pregnancy kit cost purchase fosamax with a mastercard, redness, or discomfort in the shoulder, arm, or neck, which may indicate catheter migration. Changes in the length of the external catheter segment may mean the catheter tip has migrated. Extreme care should be taken when using a break-away needle to remove the break-away introducer before threading the catheter. For placement of a catheter into the subclavian vein, place the patient in a slight Trendelenburg position with a rolled towel. Medical interventions include removing the catheter and treating any associated complications. Because visualization technologies are used during catheter insertion, quick identification of problems is possible. Catheters can be repositioned using techniques such as rapid flushing and appropriate body positioning. Catheters that loop back into the axillary or peripheral veins have a lower rate of successful repositioning. Radiographic or direct fluoroscopic observation can be used to reposition catheters. Catheters with simple looping into the subclavian, innominate, or internal jugular veins can often be repositioned by placing the patient in an ipsilateral position with the head of the bed slightly elevated. Guidewire exchange has been used with success for placing a new catheter without repeated percutaneous cannulation. Never reinsert a catheter that has been inadvertently pulled out from the exit site. Catheter occlusion is characterized by: Inability to aspirate blood Inability to flush/infuse Sluggish flow Based on a literature review, Baskin et al. Occlusion is a significant complication because it may delay or cause interruptions in infusion therapy. Causes may be attributed to either external (outside of the body) or internal problems. Causes of internal mechanical problems include pinch-off syndrome and catheter malposition as addressed in subsequent sections of this chapter. It is possible that the catheter tip abuts against the blood vessel wall, blocking the ability to aspirate blood on occasion. For example, having the patient cough or change positions may result in ability to aspirate blood. Some common drug combinations that lead to precipitate formation within the catheter have been identified (Hadaway, 2009): Phenytoin and most other solutions Vancomycin and heparin Tobramycin and heparin Fluorouracil and droperidol Dobutamine and furosemide Dobutamine and heparin the third and most common cause of occlusion is thrombotic catheter occlusion. The device is covered by a fibrin sheath as a result of a natural protective bodily response (Nakazawa, 2010). Therefore, it is clinically important to recognize and treat thrombotic occlusion. Four categories of thrombotic occlusion are commonly described in the literature: 1. However, when aspiration of blood is attempted, the tail acts as a one-way valve as it is pulled over the catheter tip. The ability to flush but not aspirate blood is considered a partial occlusion and sometimes is referred to as "withdrawal occlusion. Fibrin sheath or sleeve: A layer of fibrin forms around the external surface of the catheter, potentially coating the entire exterior wall and tip of the catheter. When a significant fibrin sheath develops and encases the catheter tip, any medication/solution that is administered can travel retrograde ("back track") along the sheath to the catheter insertion site, resulting in an infiltration/ extravasation. Infusate may be observed on the skin (nontunneled catheters), in the subcutaneous tunnel (tunneled catheters), or in the subcutaneous pocket of implanted ports.

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Sometimes during venipuncture breast cancer key chain purchase fosamax australia, you can feel a "pop" as you enter the tunica adventitia women's health center waco buy generic fosamax 35mg line. Tunica Media the middle layer 1st menstrual cycle after dc order fosamax canada, called the tunica media, is composed of muscular and elastic tissue with nerve fibers for vasoconstriction and vasodilation. The tunica media in a vein is not as strong and rigid as it is in an artery, so it tends to collapse or distend as pressure decreases or increases. Stimulation by change in temperature or mechanical or chemical irritation can produce a response in this layer. For instance, cold blood or solutions can produce spasms that impede blood flow and cause pain. Application of heat promotes dilation of the vein, which can relieve a spasm or improve blood flow. Tunica Intima the innermost layer, called the tunica intima, has one thin layer of cells, the endothelium. Valves occur at points of branching, producing a noticeable bulge in the vessel when veins are distended, for example, when a tourniquet is applied (Hadaway, 2010a). There are no diagrams listing specific locations for valves within superficial veins used for venipuncture because there is great variation among individual patients (Hadaway, 2010a). The valves may compress and close the vein lumen during the process of aspiration, thus not allowing a blood return. Blood flow via the veins is slower in the periphery and increases in turbulence in the larger veins of the thorax. This increased flow rate is an important aspect in administering hypertonic fluids because they should be administered in larger veins. When selecting the best site, many factors must be considered, such as ease of insertion and access, type of needle or catheter that is to be used, and comfort and safety Figure 6-3 Superficial veins of the dorsum of the hand. The metacarpal veins located on the dorsum of the hand are easily visualized, palpated, and accessible. Their use may be limited because of excessive fat in infants and loss of subcutaneous tissue and skin turgor in older adults. The cephalic vein follows along the radius side of the forearm; it is a larger vein and relatively easy to access. The basilic vein follows along the ulnar side of the forearm to the upper arm; it is easily palpated but moves more easily, so it is important to stabilize the vein with traction during access. The antecubital veins, including the median cephalic (radius side), median basilic (ulnar side), and median cubital (in front of elbow), are located in the bend of the elbow. Table 6-2 summarizes information on identifying and selecting the most effective I. Cephalic Radial portion of the lower arm along the radial bone of the forearm 18- to 24-gauge cannulas, usually over-the-needle catheter Basilic Ulnar aspect of the lower arm and runs up the ulnar bone 18- to 24-gauge, usually over-the-needle catheter Accessory Cephalic Branches off the cephalic vein along the radial bone 18- to 22-gauge, usually over-the-needle catheter Medium to large size and easy to stabilize May be difficult to palpate in persons with large amounts of adipose tissue. Median Cubital Communication of cephalic and basilic veins in antecubital fossa 16- to 22-gauge, overthe-needle catheter Approaches to Venipuncture: Phillips 16-Step Peripheral-Venipuncture Method Performing a successful venipuncture requires mastery and knowledge of infusion therapy as well as psychomotor clinical skills. The Phillips 16-step venipuncture method, outlined in Table 6-3 and explained in detail in this chapter, is an easy-to-remember step approach for beginning practitioners. As a nurse initiating infusion therapy, be aware of these standards as well as those of your own institution. Attention to pain management Catheter selection Gloving Site preparation Vein entry, direct versus indirect Catheter stabilization and dressing management Postcannulation 12. Labeling Equipment disposal Patient education Rate calculations Documentation Precannulation Before initiating the I. It is also essential that the nurse understand the rationale for the order before proceeding. Step 2: Hand Hygiene Appropriate and adequate hand hygiene is one of the most important steps in reducing the risk for vascular access device-related infections. Note that glass systems are used infrequently and primarily with medications that can be absorbed by plastic.

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