Monday, November 15, 2010

Fluid Management

Within the first 20 minutes of implementation make sure to check hydration, IV or Enteral fluids and record.
  • skin turgor
    • gentle pinch of subclavicular area - for tenting
    • inspection of mucous membrane - for moisture  (use gloves)
      • palpate the anterior fontanel of a child less than 1 year old - for depression
  • verify type of fluid in IV or Enteral (if continuous feeding)
  • verify rate of infusion of IV or Enteral
    • if continuous flow check rate on device - must be exact number prescribed on kardex
    • if gravity flow count gtt/min - must be within 5 gtts of calculated number of gtts/min
  • verify patency of IV or Enteral feeding tube (use gloves)
    • if IV check placement by palpating for temperature and edema
    • if Enteral check placement by aspirating gastric contents and instilling 20 - 30 cc of air prior to initiating feeding.
Throughout PCS:
  • record intake and output if assigned
  • if change or new solution required
    • access insertion site for temperature and/or edema
      • if intermittent access device check patency by checking temperature and edema and aspirate to blood return prior to flushing
      • flush with prescribed solution before and after administering medication
    • clear all air from tubing
    • regulate rate as above
  • administers the designated amount of fluid per our within the following ranges:
    • +- 25 ml/hr
    • +-10 ml if under 2

When intake is assigned:
  • measure the amount of fluid ingested or infused
  • record fluid intake within +- 10  %  of the actual intake
When output is assigned:
  • collects output
  • measures output during entire PCS
  • records amount of output within +- 10% of actual output for the PCS on the recording form
    • output from foley or other drainage device is not measured during the PCS unless otherwise designated
If assigned to discontinue an IV assess site, remove cannula, apply pressure to site and apply protective covering. record all.

Record hydration status and condition of insertion site within first 20 minutes on the recording form.

If ICD alarm sounds - verify the tubing is not kinked or the site is not infiltrated..."ask the CE or staff nurse to assist with turning off the alarm" page 149 17th edition of the CPNE Stufy Guide.

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