ADULT IV FLUID THERAPY
- ONLINE LEARNING MATERIALS FOR SAVONIA UNIVERSITY OF APPLIED SCIENCES
A U T H O R / S :
THESIS – BACHELOR'S DEGREE PROGRAMME SOCIAL SERVICES, HEALTH AND SPORTS
Mahdokht Pourdeljoo Kathryn Tourunen
SAVONIA UNIVERSITY OF APPLIED SCIENCES THESIS Abstract Field of Study
Social Services, Health and Sports Degree Programme
Degree Programme in Nursing Author(s)
Mahdokht Pourdeljoo and Kathryn Tourunen Title of Thesis
Adult IV Fluid Therapy - Online learning material for Savonia University of Applied Sciences
Date 29th April 2021 Pages/Appendices 40/4
Supervisor(s) Leena Koponen
Client Organisation /Partners
Savonia University of Applied Sciences, Savonia UAS Abstract
This thesis was carried out as a development work for the NURKLÄÄ1 Basics of Pharmacotherapy -course at Savonia University of Applied Sciences. The produced learning material was made for the second-year nursing students about the initial fundamental concepts of adult-intravenous fluid therapy. This online learning material aims to develop students´ knowledge of IV fluid therapy (body fluids, electrolytes, intravenous solutions), to support their independent learning, and to improve the content of this course. The authors´ theoretical knowledge and practical skills about the topic has significantly promoted alongside the implementation of this material.
In this thesis, the essential information of fluids, electrolyte balances & disturbances, and IV types in addition to important facts about the nursing IV safe management have been collected from prestigious original textbooks and articles. Furthermore, this study had a view of the best possible teaching methods of this subject to nursing students as adult learners in the virtual learning environment. The authors made this educational online material, in form of an interactive PowerPoint presentation with 62 slides consisting of test questions in between each main topic and voice recorded over a few choice slides. This non-graded self-study online material is a part of NURKLÄÄ1 Basics of Pharmacotherapy course and has been added to the Moodle platform as a supplementary material of the course lecture. This product was piloted with the international registered nursing groups at Savonia UAS and their feedback was analyzed through the Webropol survey. The main research question of this study was “How do the online materials in NURKLÄÄ1 Moodle improve the knowledge of IV fluid therapy after completing the PowerPoint?”
Further possible studies could be conducted regarding the implementation of the IV therapy methods in skill labs. Hence, the accuracy of aseptically IV administered by students in the internship placements can be reas- sured. Moreover, it would be beneficial to deepen students´ understanding of the IV fluid in a resuscitation situation.
Keywords
fluid balance, fluid therapy, electrolyte imbalances, IV fluids, nursing management, teaching, nursing students, adult learners, VLE, learning material.
1 INTRODUCTION ... 5
2 FUNDAMENTAL CONCEPTS OF FLUID, ELECTROLYTE BALANCES & DISTURBANCES AND IV- FLUID TYPES ... 7
2.1 Body Fluids and their compositions ... 7
2.2 Fluid volume disturbances: Hypovolemia and Hypervolemia ... 8
2.2.1 Hypovolemia ... 9
2.2.2 Hypervolemia ... 9
2.3 Electrolyte imbalances: Sodium, Potassium and Calcium imbalances ... 10
2.3.1 Sodium ... 11
2.3.2 Potassium ... 12
2.3.3 Calcium ... 14
2.4 IV Fluid Therapy ... 16
2.4.1 Osmolality, tonicity and osmosis... 16
2.4.2 Isotonic solutions ... 16
2.4.3 Hypotonic solutions ... 18
2.4.4 Hypertonic solutions ... 19
3 SAFE IV-MANAGEMENT IN NURSING... 20
3.1 The 10 rights of medication administration ... 20
3.2 The importance of aseptic techniques ... 22
3.3 Nursing Interventions – ABCDE ... 23
3.4 Nursing management with systematic and local complications of IV fluid therapy ... 24
4 ADULT LEARNERS ... 25
4.1 The adult learning theory ... 25
4.2 Virtual learning environment and PowerPoint ... 25
4.3 Testing knowledge ... 27
5 PURPOSE AND AIM OF THE DEVELOPMENT WORK ... 28
6 IMPLEMENTATION OF THE DEVELOPMENT PROJECT ... 29
6.1 Theoretical description of the development methods ... 29
6.2 Development implementation plan and collection of material ... 31
6.3 Development work assessment plan and data analysis ... 33
6.4 Piloting the thesis and results ... 35
7 DISCUSSION ... 37
7.1 Evaluation of development process and output ... 37
7.2 Ethics and reliability ... 38
7.3 Professional growth and development ... 39
7.4 Utilisation and future development ideas ... 39
REFERENCES ... 41
LIST OF FIGURES AND TABLES
FIGURE 1. Clarification of fluid compartment image ………8FIGURE 2. Movements of fluid and solution tonicity in isotonic solutions………..17
FIGURE 3. Movements of fluid and solution tonicity in hypotonic solutions………..18
FIGURE 4. Movements of fluid and solution tonicity in hypertonic solutions………..19
TABLE 1. Principal electrolytes and their functions ………..……..11
TABLE 2: The 10 ‘Rights’ for safe multidisciplinary drug administration ………..…..21
TABLE 3: ABCDE Assessment Tool ………...….23
TABLE 4: Stages of implementation of digital learning material...32
TABLE 5: Stages of doing the thesis/Stages of work………...………34
TABLE 6: Webropol Survey Results – Percentages & Mean/Average……….………..35
TABLE 7: Webropol Survey Results – Mean or Average.……….………..….36
1 INTRODUCTION
Intravenous (IV) fluid therapy has always been considered a core topic in all nursing education pro- grams in the world. However, teaching students about IV fluid therapy is one of the most challenging contents in nursing studies for education providers (Kisch & LoVerde 2015, 189). In the curriculum of the nursing programs, IV fluid therapy can be taught by using one or many different pedagogical methods. For instance lectures, workshops, or skill labs are the most common teaching methods used in nursing schools. Nursing students as adult learners conducting their internships in various complex nursing care environments will see the importance of IV therapy as a main treatment option for nearly all hospitalized patients (Indarwati & Primanda 2021, 397.) Adult IV fluid therapy is one of the most common treatment strategies prescribed by medical professionals and performed by nurses in differ- ent clinical settings (Salmela, Pöyry & Granat 2018, 3).
In the Finnish Bachelor’s Degree Programme in Nursing, IV fluid therapy has been taken into consid- eration as an important subject within all universities of applied science’s (UAS) curriculums. Nurses responsible for general nursing care are regulated by directive 2013/55/EY of the European Parliament and of the Council and by European Qualifications Framework, 2006 (Directive 2013/55/EU. Directive of the European Parliament and of the Council on the recognition of professional qualifications). At Savonia UAS, the second academic year nursing students will start learning the fundamental concepts of IV fluid therapy in the course named NURKLÄÄ1 Basics of Pharmacotherapy (Savonia UAS Curric- ulum Course Table).
The learning process of IV fluid therapy starts from knowing what body fluid is, what the classification of fluid compartments are, and how fluid distribution within the compartments occurs. The purpose of any IV administration is to support the main organs to keep the body fluid in balance which is known as homeostasis. The body is able to compensate for minor imbalances. However, in response to fluid excess or fluid deficits the body itself is not able to resist and as a result an individual might require medical attention. (Davidson & Lyman 2010, 48.) It is extremely important for nurses to learn all the aspects of fluid therapy including theoretical bases and clinical techniques as understanding the fundamental concepts of fluid balance and therapy is the key to success for students to build up their knowledge and develop their practical skills in future careers (Indarwati & Primanda 2021, 397).
Nurses should have knowledge and practical training in the three types of parenteral routes of admin- istration. These three adminstration routes are subcutaneous, intramuscular and intravenous routes (Ruiz & Montoto 2018, 1–2). Intravenous (IV) fluid therapy is a broadly used method to provide the maintenance of body fluid and/or electrolytes balance, to replace and correct fluid and/or electrolytes deficits and, in addition, to administer drugs or blood products. Relying on the reasons for fluid ther- apy, different IV solutions such as hypotonic, isotonic, and hypertonic might be applied. (Hinkle &
Cheever 2018, 256–288.) Depending on the types of imbalances nursing interventions and manage- ment in regards to patients receiving IV fluid therapy vary a lot. However, parts of safe IV manage- ment, including the 10 medication rights, aseptic techniques and relative nursing assessments con- sidering ABCDE, are the same in any patient cases demanding IV infusions. Health care professionals including nurses, need to have fundamental knowledge and practical skills to help prevent and treat various fluid and electrolyte disturbances in patients. (Mulvey 2018, 252.)
Among many teaching methods of fluid therapy targeted for nursing students, study outcomes em- phasize the importance of having both theoretical and practical training sessions together with e- learning materials. Other results show that nursing students would like to experience an interactive form of learning methods combined with technology. (Kisch & LoVerde 2015, 189.) To support the nursing students in their study progress as adult learners with specific learning styles, virtual learning environments have become a popular educational tool widely used around the world (De Souza-Junior, Mendes, Marchi-Alves, Jackman, Wilson-Keates & Godoy 2020, 24–30).
As IV fluid therapy is such an important topic to learn and understand in nursing studies the authors as nursing students felt that working on this topic and providing further educational material could be beneficial for future nursing students. This thesis has therefore been done to provide supplementary materials for the course NURKLÄÄ1 Basics of Pharmacotherapy. It is conducted in cooperation with Savonia University of Applied Sciences in Kuopio, Finland, and is going to be used as a part of NURKLÄÄ1 Basics of Pharmacotherapy course in the Bachelor´s Degree Programme in Nursing. The target group is second-year nursing students who are intended to have a good knowledge and un- derstanding of this specific topic of IV fluid therapy. The objectives set by this course are included in NURKLÄÄ1 Basics of Pharmacotherapy course curriculum. (Savonia UAS Curriculum Course Table.
The research question for this thesis was: How do the online materials in NURKLÄÄ1 Moodle improve the knowledge of IV fluid therapy after completing the PowerPoint?
The purpose of this development work was to produce Moodle online learning materials for Savonia UAS NURKLÄÄ1 Basics of Pharmacotherapy Course for 2nd academic year adult nursing students. The online learning materials will include a PowerPoint presentation (PPT) and inclusive short test ques- tions to evaluate the student’s learning and knowledge of the subject. The aims of the learning ma- terials are to advance and evaluate students´ knowlege of IV fluid therapy (body fluids, electrolytes, intravenous solutions.) The other aim was to support independent learning to achieve the course goals. All these will aim to improve the content of this course.
2 FUNDAMENTAL CONCEPTS OF FLUID, ELECTROLYTE BALANCES & DISTURBANCES AND IV-FLUID TYPES
This chapter looks into the main concepts of body fluids, their compositions and where the fluids are stored within the body. The text also goes into depth about the main body fluid or electrolyte disturb- ances or imbalances including hypovolemia & hypervolemia and sodium, potassium & calcium imbal- ances, plus the main symptoms, and how to evaluate and treat them.
2.1 Body Fluids and their compositions
Body fluid is defined as an existence of water and dissolved substances within the human body. These include the electrolytes sodium, potassium, calcium, magnesium, phosphorus and chloride. Other sub- stances are gases which include oxygen and carbon dioxide, plus nutrients, enzymes and hormones.
Approximately 60 % of an adult’s total body weight consists of fluid. However, these amounts may vary in age, gender and body fat. (Peate & Nair 2018, 38.)
Electrolytes, also known as ions, are the charged particles in body fluids that help to transmit electric impulses or messages throughout the body for proper nerve, heart and muscle function. Positive ions are called Cations, Negative ions are called Anions. There are supposed to be equal amounts of cations and anions in the body. Any disturbance of this balance can have severe consequences, if not fatal.
(Peate & Nair 2018, 46–48.)
Fluids and electrolytes play important roles in normal bodily functions. One of the main vital functions is homeostasis which refers to the stability of the composition and volume of body fluid within the normal range. It occurs as a result of cooperation of several organs such as the heart, kidneys, lungs and endocrine glands together with the hormones. In general, fluid balance is connected to the elec- trolyte balance. Any disturbances in the body fluids balance, water and electrolytes, might lead to serious complications for instance, dehydration, bleeding, hypovolemic shock, coma and even death.
(Hinkle & Cheever 2018, 256–287.)
The majority of body fluid comprises water, where most nutrients, electrolytes and minerals are dis- solved. Water alone makes up for about 60 % of the total body weight. (Adams, Holland & Urban 2014, 314.) Studies show that in an average 70 kg adult, the total amount of biofluids is 40 litres, averaging 60 % of a total person’s body weight. Body fluid can be located in two different areas as seen in Figure 1. These compartments are separated by capillary walls and cell membranes (Williams, Wilkins & Willis 2015, 19.) Approximately 2/3 of total body fluid or 40 % of body weight is located inside cells. This is known as IntraCellular Fluid (ICF.) The remaining 1/3 of body fluid or 20 % of body weight is located outside cells. This is known as ExtraCellular Fluid (ECF). (Adams et al. 2014, 314.) ECF itself further divides into two important parts. ExtraCellular fluid further divides into two important parts - fluid in the intravascular space within the blood vessels, for example, plasma, and fluid in the extravascular space outside the blood vessels. Extravascular fluids, which is later on re- ferred to as ECF, can be found in the interstital space in the tissues. It is also located between the cells and outside the blood vessels, like lymphs, and in the transcellular space, which is the minor compartment. Transcellular fluid is secreted by epithelial cells which comprise of GI fluids, peritoneal, cerebrospinal and synovial fluids (Potter 2015, 464).
FIGURE 1. Clarification of fluid compartment in the body and its proportion in percentage for an average adult with 70kg weight (modified from https://www.physiologyweb.com/figures/physiology_illustra- tion_tPksfgTyDcZ10zEq1Wp1FqLjrBRL8IGL_body_fluid_compartments_of_a_70_kg_adult_man.html.)
Body fluid constantly moves between spaces and compartments through cell membranes to control water balances or in general to maintain the body homeostasis. Water exchanges freely but transpor- tation for larger molecules and electrolytes with charges is different. It is important to highlight the fact that body fluids must contain specific amounts of these essential ions (or electrolytes) and must also be maintained at particular pH values. Plasma pH is the acidity or alkalinity of the blood. The definition of pH is the hydrogen ion (H+) concentration in the bloodstream. The normal range of pH in blood is 7.35 to 7.45. If acids or bases accumulate in the system, it changes the pH, and if left untreated, it can result in death. (Adams et al. 2014, 314; Hinkle & Cheever 2018, 283.)
2.2 Fluid volume disturbances: Hypovolemia and Hypervolemia
This chapter provides information about hypovolemia and hypervolemia and the nursing interventions and treatment in order to manage these disturbances.
The volume and composition of body fluids must be sustained within narrow parameters. Excess body fluids can cause hypertension, congestive heart failure and/or peripheral edema (Adams et al. 2014, 314.) Peripheral edema is swelling of the feet, ankles or legs caused by the build-up and retention of fluid in leg tissues (Hinkle & Cheever 2018, 686). Some other problems caused by fluid deficiency in the body are hypotension (low blood pressure), increased blood clotting, problems with kidney func- tions, that in more severe cases can lead to renal failure or even constipation. Further complications can also be multisystem failure, an increased risk of infection or an imbalance of electrolyes. (Peate
& Nair 2018, 38.) Decreased fluid volume can result in dehydration and in worse case scenarios even shock. Too little or too much of an electrolyte can have serious consequences for a patient and must be quickly resolved (Adams et al. 2014, 314.)
2.2.1 Hypovolemia
Fluid volume deficit (FVD) also known as hypovolemia refers to the condition of losing water and electrolytes from ECF compartments. The total body fluid volume will decrease but the proportion of water and electrolytes in the body fluid remains the same. It occurs as a result of abnormal fluid losses such as vomiting, diarrhea, gastrointestinal suctioning, sweating and fever which can lead to excessive fluid output in comparison to fluid intake. Other conditions like burning, edema, bleeding, anorexia, nausea and uncontrolled diabetes may also reduce fluid intake. (Hinkle & Cheever 2018, 259.)
Signs or symptoms of FVD are as following: the patient’s weight, skin’s elasticity or turgor, blood pressure and Central Venous Pressure (CVP) can alleviate remarkably. Patients with FVD may experi- ence also high pulse rate, dizziness, weakness, thirst, confusion, nausea, high body temperature, pale skin and muscle cramps. In severe cases, loss of consciousness and coma has been reported. In addition to all above, another sign of hypovolemia is oliguria defined as urine output less than 400 ml per day. (Hinkle & Cheever 2018, 259–260.)
Hypovolemia can be assessed and evaluated through laboratory tests. When results display a high Blood Urea Nitrogen (BUN) to creatinine ratio, increased level of hemoglobin and hematocrit as well as elevated urine specific gravity and osmolality. Based on the severity of fluid loss, FVD can be treated orally or through an IV route with Isotonic electrolyte solutions; for instance, lactated Ringer solution or 0.9 % sodium chloride. (Hinkle & Cheever 2018, 259–260.)
It must be noted that hypovolemia is often confused with dehydration. In both cases, there is an unsual loss of water and fluid, however, in hypovolemia the proportion of water and electrolytes in the body fluid remains the same, but in dehydration serum sodium level will increase. (Hinkle &
Cheever 2018, 259.) 2.2.2 Hypervolemia
Fluid volume excess (FVE) or hypervolemia is defined as fluid overloads in the ECF spaces as a result of unusual retention of water and solutes. Similar to hypovolemia, the proportion of water and sodium remain the same, however, the total body fluid has been increased significantly. Hypervolemia is considered a medical condition and occurs when the patient has underlying diseases such as heart and kidney failure or cirrhosis of the liver. Pathophysiologically, abnormal kidney function, acute onset of diabetes or some metabolic disorders can lead to loss of hemostatic mechanism balance and can explain some of the reasons causing FVE. Other causes of FVE can be over the administration of sodium-containing fluids or plasma protein like Albumin. (Hinkle & Cheever 2018, 259–262.)
Patients with hypervolemia have signs and symptoms which include edema, distended neck veins and weight gain of about 1 kg per day, which is equal to gain of 1 liter fluid. They may also have hyper- tension, higher CVP and respiratory rate, as well as an increasing level of urine output. (Hinkle &
Cheever 2018, 259–263.)
Lab tests illustrate a low value for BUN and hematocrit and reduced hemoglobin and hematocrite.
Furthermore, there is a reduction in urine sodium level and specific gravity. Depending on the causes
of FVE, the first-line treatment of hypervolemia after trying sodium dietary restriction will be diuretics to eliminate extra fluids from the body as urine. (Hinkle & Cheever 2018, 262–264.)
A medical professional will look through the patient’s assessments carefully. In these cases, it is im- portant to check and examine the patient’s fluid intake and output (I & O) level, weight, vital signs and central venous pressure regularly. It is necessary to evaluate other signs or symptoms like level of consciousness, skin color and edema in order to determine the progress of IV therapy. Moreover, looking at the patient’s hemodynamic response to volume replacement is an important factor that is essential to take into consideration. Both hypo- and hypervolemia can be evaluated by checking the patient’s medical history, doing a physical assessment and taking laboratory tests which include a complete blood count test and urine sample test. Blood factors like Blood Urea Nitrogean (BUN) and its association with serum creatinine concentration are the keys for assessing hypovolemia, while, in case of hypervolemia, BUN and hematocrit are important factors to be analyzed. (Hinkle & Cheever 2018, 259–264.)
Nursing interventions with patients diagnosed with fluid imbalances include monitoring, measuring and regularly documenting the vital signs. Specifically in the case of hypovolemia symptoms include a rapid pulse, low blood pressure, hypothermia, vomiting, nausea and diarrhea. Exact observations of orthostatic hypotension need to be taken. Other additional checks that need to be made are the skin color and its elasticity and checking the patient’s daily weight measurement, as losing 0.5 kg per day is equal to the loss of approximately 500 ml fluids per day. Nurses also need to monitor the patient’s level of consciousness by means of the Glascow coma scale (https://www.glasgowcomascale.org/;
Jain & Iverson 2020, 1–9.) Further essential nursing interventions include measuring the patient’s fluid input & output, dependant on doctor’s orders, and in case of acute hypovolemia monitoring the intensity of fluid loss for every 8 hours or more hourly. In addition to all the above, it is crucial to assess the patient’s mental health status. Nursing management in a patient with hypovolemia and hypervolemia is almost the same. However, in cases of hypervolemia, it is important to take into consideration the respiratory values; rate, rhythm, strength, intensity and breath sounds regularly. In addition, evaluating the degree of edema is highly recommended. (Hinkle & Cheever 2018, 260–264.) Nurses have to identify patients at risk for FVD and try to encourage them to raise their fluid intake orally. Alongside offering all types of oral fluids to the patient, a small volume of oral rehydration solutions that provide fluid, glucose and electrolytes in concentrations also would be a great option to improve body fluid loss. On the other side, to prevent hypervolemia, first sodium-restricted diets are suggested to try, and secondly, it is vital to warn the patients about the hazards of not consulting with the healthcare professionals in case of taking over counter medications with a possible chance of sodium contain. (Hinkle & Cheever 2018, 260–264.)
2.3 Electrolyte imbalances: Sodium, Potassium and Calcium imbalances
In order to function normally, the body must be able to maintain the levels of electrolytes within very narrow parameters (in section 2.1.). Electrolytes are salts and minerals that are found in the blood, with the major three electrolytes being sodium, potassium and calcium. These narrow parameters that need to be maintained are controlled by hormones. The main four hormones are antidiuretic
hormone, aldosterone, atrial natriuretic peptide and parathyroid hormone. These hormones provide signals that enable the body to sustain the levels of electrolytes in each area, in the cells, tissues or organs. Simply put, the body moves electrolytes into or out of the cells based on the signals provided by the hormones. (Peate & Nair 2018, 47–51.)
The levels of electrolytes are maintained principally by the kidneys and the GI tract. Electrolytes are lost on a daily basis due to normal excretory functions namely urinary output and faeces. However, these losses must be replaced by adequate intake of fluids by staying hydrated and with good nutri- tion, otherwise there could be an imbalance in electrolytes as a result. (Adams et al. 2014, 319.) TABLE 1: Principal electrolytes and their functions (modified from Peate & Nair 2018, 47–48)
Electrolytes Normal values in ECF (mmol/L)
Function Main distribution
Sodium (Na+)
135-145 Important cation in generation of action poten- tials. Plays an important role in fluid and elec- trolyte balance. Increases plasma membrane permeability. Helps promote skeletal muscle function. Stimulates conduction of nerve im- pulses. Maintains blood volume.
Main cation of the ECF
Potassium (K+)
3.5-5 Important cation in establishing resting mem- brane potential. Regulates acid-base balance.
Maintains ICF volume. Helps promote skeletal muscle function. Helps promote the transmis- sion of nerve impulses.
Main cation of the ICF
Calcium (Ca2+)
8.5-10.5 Important clotting factor. Plays a part in neu- rotransmitter release in neurones. Maintains muscle tone and excitability of nervous and muscle tissue. Promotes transmission of nerve impulses. Assists in the absorption of vitamin B12.
Mainly found in the ECF
2.3.1 Sodium
Sodium (Na+) is a cation, a positive ion. It is located in the Extracellular Fluid, and is the most abun- dant electrolyte found here. It plays a pivotal role in overall fluid distribution within the body. (Hinkle
& Cheever, 2018, 264, 320–321.) Water travels toward or with Na+. Sodium controls water distribu- tion throughout the body as it does not easily transfer across the semi-permeable cell wall membrane.
Sodium is abundant in the body and has a high concentration. It is also important for neuromuscular physiology and the maintenance of acid-base balance. Sodium levels are also connected to blood pressure. In cases of too little sodium the blood pressure decreases, and in cases of excess sodium the blood pressure rises. Sodium also plays an important role in maintaining osmolality (i.e. concen- tration) and in transmitting nerve impulses. Normal sodium concentration ranges between 135-145 mmol/L. (Hinkle & Cheever 2018, 264, 320–321; Peate & Nair 2018, 47–48.)
Hyponatremia is when there is a decreased sodium level in the bloodstream, less than 135mmol/L.
Clinical manifestations need to be recognised by nurses, and can present in many different ways, with early common symptoms being headache, lethargy, dizziness, nausea & vomiting, reduced blood pressure, abdominal cramping, etc. (Hinkle & Cheever 2018, 265–267.) Later signs of progressed hyponatremia include muscle twitching or tremors, as well as altered neuological function such as confusion, lethargy, convulsions or in severe cases even coma (Adams et al. 2014, 322). Contributing factors can come in a many different ways, for example, loss of GI fluids, loss of sodium with use of diuretics, renal disease, hyperglycemia, heart failure (Hinkle & Cheever 2018, 265–267). This condition may also result from increased sodium loss due to disorders of the skin, for example, a burns victims or those with extended fever or extreme sweating (Adams et al. 2014, 322). Early diagnosis and treatment of hyponatremia are vital to prevent these further symptoms developing or for serious long- term neurological issues to be prevalent in the patient (Hinkle & Cheever 2018, 265–267). Loop diu- retics are used to treat hyponatremia when excessive dilution (i.e. drinking too much water) is the cause. Where the cause is sodium loss, treatment is by oral or parenteral NaCl or then with IV fluids that contain salt, such as lactated Ringer. (Adams et al. 2014, 322.)
Hypernatremia is the opposite of hyponatremia, being that there is an excess of sodium rising above 145 mmol/L. Clinical manifestations of hypernatremia include thirst, fatigue, muscle twitching, con- vulsions, and can even lead to a decreased level of consciousness in an individual or an altered mental state. The most common cause of hypernatremia is renal disease where there is decreased elimination of Na+. Other causes may also be extreme intake of sodium, watery diarrhea, fever or burns. In order to treat hypernatremia, it is dependant on whether the condition is minor or acute. For minor hyper- natremia just eating a low sodium diet may be effective in reducing the sodium to normal levels;
however in an acute situation the goal of the treatment is to quickly and effectively return the con- centration of the plasma to normal. In doing so it is also dependant on whether the patient is hypovo- lemic or hypervolemic. In the case of hypovolemia IV fluids will need to be administered, either 5 % dextrose or 0.45 % NaCl to increase the plasma volume, whilst at the same time reducing the con- centration of the plasma. However if the patient is hypervolemic, then diuretics are the medication to be used to eliminate the excess Na+ and fluid from the body. (Adams et al. 2014, 321.)
2.3.2 Potassium
Potassium (K+) is a cation, a positive ion. It serves an integral role in maintaining and regulating osmolality, the concentration of dissolved particles, in the intracellular space. It also helps to maintain acid-base balance. (Adams et al. 2014, 322.) Potassium is located mainly in the ICF, and is the most abundant of the total electrolytes volume found here. 98 % of potassium is found in the ICF, the remaining 2 % of potassium is found in ECF. Potassium influences both skeletal and cardiac function and cardiac muscle activity, for example, alterations in the osmolality of potassium has an affect on myocardial irritability, which disturbs the rhythm of the heart. Potassium is also vital to neuro-muscular function. (Peate & Nair 2018, 47; Hinkle & Cheever 2018, 268.) Potassium is constantly on the move, both in and out of cells. This happens through the sodium-potassium pump. (Hinkle & Cheever 2018, 268.) Normal levels of serum potassium, for example, the amount of potassium in the blood serum, the fluid part of the blood, ranges from 3.5 to 5 mmol/L. Potassium is not naturally preserved by or
stored in the body, therefore a certain amount of potassium must be consumed on a daily basis.
Approximate guidelines are 40 mmol per day. (Williams et al. 2015, 160.)
In order for the body to regulate and maintain potassium balance, the renal system must be properly functioning as 80 % of the daily potassium eliminated by the body is excreted through the kidneys through urinary output. The remaining 20 % lost is through sweat and stools. (Hinkle & Cheever 2018, 268.)
Hypokalemia is when the level of serum potassium falls below 3.5 mmol/L. It can be classified into moderate hypokalemia ranging between 2.5 – 3 mmol/L or severe hypokalemia, when the level falls below 2.5 mmol/L. Because the parameters are so small for potassium levels, even a minor decrease in potassium can have a huge effect on a patient, therefore it is very important to monitor the potas- sium levels carefully and precisely. (Williams et al. 2015, 160.) Clinical manifestations of hypokalemia include muscle weakness, anorexia, lethargy, leg cramps, confusion, drowsiness, abnormal abdominal bloating, disrhrythmias that can lead to cardiac arrest and in severe cases even death. Hypokalemia can result from using high doses of loop diuretics, for example, furosemide, or from severe diarrea or vomiting. Nasogastric suctioning and major GI surgery can also be underlying causes of hypokalemia.
(Adams et al. 2014, 323.)
Mild cases of hypokalemia are treated with increasing the dietary intake of potassium, by introducing potassium-rich foods into the diet (i.e. dried fruit or nuts, avocados, bananas, bran cereals, etc). There are also oral potassium supplements available to take. (Adams et al. 2014, 323; Williams et al. 2015, 161.) However, in severe hypokalemia, dietary intake is not enough and potassium needs to be given via the parenteral route (Adams et al. 2014, 323). However, beware! If potassium is given too quickly, it can cause cardiac arrest, so it cannot be given as an IV push or bolus. (Williams et al. 2015, 169.) IV push means a diluted medicine or antibiotic administered directly into the IV line, but with the minimal amount of fluid volume (Spencer, Ipema, Hartke, Krueger, Rodriguez, Gross & Gabay 2018, 157). Instead, potassium should be administered via a pump so that it can be regulated and set as an infusion over at least an hour’s period (Astle 2005, 37). It is generally recommended that IV po- tassium infusion does not exceed more than 10 mmol/hr (Burchum & Lehne 2016, 462).
It is also important to note that potassium is very irritating to tissues and peripheral veins, therefore an IV potassium infusion is usually recommended to be administered via a central line to prevent this irritability from occuring (Hinkle & Cheever 2018, 290–294).
Hyperkalemia is when the serum potassium level rises above 5 mmol/L. Generally hyperkalemia occurs less frequently than hypokalemia, however it is more serious. It is more prevalent in premature infants due to their renal function being yet immature and it is also prevalent in elderly patients (usually aged 60 or older) due to deterioration of renal function and decreased urine output. (Williams et al. 2015, 177.) Some of the signs and symptoms of hyperkalemia are muscle weakness, cramps, abdominal distention, dysrhythmia and paresthesias, which is a burning or prickling sensation or numbness or tingling mainly in the hands, arms, legs or feet. Other symptoms include irritability and/or anxiety, and changes in the ECG reading. (Hinkle & Cheever 2018, 269.) Cardiac complications are also a
symptom of hyperkalemia, which include a decreased heart rate, irregular pulse, decreased cardiac output, and in some cases it can lead to cardiac arrest, which can be fatal (Williams et al. 2015, 177).
Hyperkalemia is associated with too much intake of potassium and not enough output – this leads to a toxic build-up of potassium in the kidneys. Too much potassium can come through simply eating too much potassium in the diet, usage of excessive salt substitutes or over-use of potassium supple- ments which in turn all lead to increased potassium levels. This, sidelined with decreased urine output, causes the potassium levels to build up and become toxic, with excessive doses resulting in hyper- kalemia. There are also a number of drugs that can cause hyperkalemia, for example, antibiotics, digoxin, heparin and chemotherapeutic drugs. (Williams et al. 2015, 173.) Renal disease is the most common cause of hyperkalemia (Simon, Hashmi & Farrell 2020, 1–9).
Treatment depends on the severity of the condition; in mild hyperkalemia treatment involves loop diuretics, a reduced-potassium diet and careful monitoring and review of medications that may be associated with high-potassium levels. However, in cases of more severe hyperkalemia, diuretics may not be enough particularly in patients with underlying renal disease. For more severe hyperkalemia there are a number of different treatments available, which include 10 % calcium gluconate OR 10 % calcium chloride to counteract the myocardial effects of hyperkalemia. Kayexalate can also be admin- istered Per Os, orally by mouth or via nasogastric tube (NG), or also as a retention enema. (Burchum
& Lehne 2016, 462; Williams et al. 2015, 179. Simon et al. 2020, 1–9.) A further treatment option is dialysis, which is the process to filter waste and water from the blood through a filter called a dialyzer also known as an artificial kidney. This option is used in renal failure cases. (Vadekedath & Kandi 2017, 1.)
2.3.3 Calcium
Calcium, Ca+2 is another common mineral regulated in the body system for various purposes. In healthy individuals, the total calcium normal range is 2.2 to 2.6 mmol/L. It is proved that over 99 % of the body's calcium is situated in the skeletal system. Calcium is an important element in the for- mation and metabolism of bones and teeth targeted towards supporting their structure and hardness.
Despite its primary role in bone structures, the body uses calcium for other objectives as well. In the neural system, calcium facilitates the transmission of nerve impulses, consequently, stimulated cardiac muscle will have contractions and relaxations. Other than these, it takes a role in the blood coagulation process by activating the blood-clotting factors. (Hinkle & Cheever 2018, 272–273.)
Sources of calcium are available in numerous types of food including; dairy products, vegetables, grains, legumes, fruits, eggs, to some extend also meat, fish, and poultry. In addition to all mentioned earlier, dietary supplements like vitamin D is highly recommended to be taken, , since it improves the absorption of calcium in the body. (Ross, Taylor, Yaktine & Del Valle 2011, 1–4.)
Hypocalcemia is the deficiency of calcium or a diminished serum calcium level under 2.2 mmol/L. It occurs in many clinical situations and can be seen more often when there are insufficient levels of vitamin D and parathyroid hormones, or as a result of resistance to these hormones. Osteoporosis, hypoparathyroidism, and its related post-operative complications or conditions like pancreatitis, and kidney injuries are good examples of hypocalcemia. Older adults who are bed-patients with fewer
mobilities or those who are drinking too much alcohol are at risk for hypocalcemia. (Hinkle & Cheever 2018, 273–275.)
Patients with hypocalcemia complain of numbness, tingling of fingers and toes. Other signs and symp- toms are anxiety, low blood pressure, bronchospasm, irritability and possibly seizures, and impaired clotting time. Treatment options begin with calcium and vitamin D supplements orally. Depending on the cases, medications like thiazide diuretics, phosphate binders, and a low-salt and low-phosphorus diet will be tested. In acute and potentially life-threatening cases, there is an urgent need for intra- venous calcium. An early intervention for patients at risk for hypocalcemia is to educate them about calcium-rich diets and the importance of taking supplements daily which can avoid potential calcium deficiency in the body. Habits like drinking too much alcohol or caffeine affect calcium absorption.
Moderate smoking also has an impact on the increasing level of urinary calcium output. Therefore, it is recommended to encourage patients to make changes in their lifestyle. (Khan & Fong 2012, 158–
162.)
Hypercalcemia is defined as serum calcium level over 2.6 mmol/L and it is considered a very dangerous condition. Some examples which explain causes of hypercalcemia are hyperparathyroidism, malignant tumors, prolonged immobilization, and supplement misuse; for example over-use of calcium sources or vitamin D. (Hinkle & Cheever 2018, 275–276.)
Patients with hypercalcemia feel weakness in their musculoskeletal systems and probably have deep pain in the bone. There is risk for bradycardia, heart block, hypertension, constipation, polyuria, ano- rexia, nausea, and vomiting. In addition to all above, it has an influence on the central nervous system in different ways; such as impaired mental abilities, depression, psychosis, altered consciousness which means confusion, lethargy, stupor, and coma. (Auron & Alon, 2018, 1475–1488.) Hypercalcemia is linked to cancer patients who undergo surgery or are treated with chemotherapy and radiation therapy. The same as hypocalcemia, nursing management emphasizes the identification and assess- ment of patients at risk. With patients at risk, it is important to encourage them to be physically active and drink approximately 2.8-3.8 L of fluids daily. IV fluids containing NaCl, sodium, are the best options to help to rise the exertion level of calcium unless contraindicated. About mental changes, it is important to inform the patient and family that it is reversible along with treatment. (Hinkle &
Cheever 2018, 275–276.)
2.4 IV Fluid Therapy
This section briefly talks about the terms osmolality, tonicity and osmosis. It also talks about the three main groups of of IV solutions, which are isotonic, hypotonic, and hypertonic solutions. These solu- tions are prescribed by medical professionals depending on the purpose of the administration. (Hinkle
& Cheever 2018, 288.) Adult patients often require IV fluid therapy for different purposes when hos- pitalized. The main indications for fluid therapy are to maintain body-fluid volume, to replace and correct abnormal fluid and electrolyte losses, and/or to support daily nutritional needs. Another com- mon indication for fluid therapy is the administration of medications and blood products into the vein.
(Pahdi, Bullock & Stroud 2013, 347.) 2.4.1 Osmolality, tonicity and osmosis
For a better understanding of the fluid balance concept, it is important to become familiar with the definitions of the following terms: osmolality, tonicity and osmosis. Osmolality discusses the total number of solutes in milliosmoles or dissolved particles in one kilogram of solvent or water. Osmolality can be measured accurately in laboratory settings and is mainly used to evaluate serum and urine level. The normal range of body fluid osmolality is between 275-295 mOsm/ad. (Adams et al. 2020, 337.) Tonicity is a general term defined as the capability of a solution to make changes in water movements across the cell membrane by means of osmosis pressure. When administrating various types of IV fluids, it is essential to keep in mind that plasma tonicity is considered as a reference point.
(Adams, Holland & Urban 2020, 337.) Osmosis is the term used for the process of water movement through a semipermeable membrane from low solute concentration to high solute concentration and it continues until solute concentrations are at the same level (Hinkle & Cheever 2018, 253).
2.4.2 Isotonic solutions
Solutions with the same concentration of solutes in plasma are considered isotonic (Iso = equal, tonic
= concentration of a solution). In comparison with plasma as an isotonic solution, solutions containing a lower or greater concentration of solutes are called hypotonic and hypertonic. (Adams et al. 2020, 337.)
Isotonic can be described when there is an equal concentration of solutes in both ICF and ECF spaces.
In other words, in normal conditions there is the same osmolality in both intracellular and extracellular spaces. In figure 2, no net fluid shifts, no changes on cells and red blood cells can be seen in move- ments of fluid and solution tonicity in isotonic solution. Isotonic solutions administered at hospital settings have a total osmolality close to the ECF. Giving such solutions to the patients expands the ECF volume. (Hinkle & Cheever 2018, 288.)
ICF
Fluid shift
ECF
Solutes
Normal Plasma Volume
FIGURE 2: Movements of fluid and solution tonicity in Isotonic solutions (Modified from Adams et al.
2020, 338)
Since isotonic solutions are one type of crystalloid fluid which can be diffused rapidly into the ECF spaces, consequently plasma or intravascular volume will also enlarge. It should be noted that having a 1 litre isotonic solution will expand ECF into 0.75 litres but plasma in 0.25 litres, therefore, to replace 1 litre of blood loss, we need to have 4 litres of isotonic solutions. It is important to become familiar with the importance of fluid administration, features of isotonic solutions and what changes they can make in the body. In the case of administering isotonic solutions, monitoring a patient’s vital signs carefully, in particular patients with hypertension and heart failure, is very crucial. (Hinkle & Cheever 2018, 288–289.)
As the result of blood loss, postoperative complications, dehydration and any reasons for fluid loss extracellularly, or in general to increase the ECT fluid volume, to promote urine output and to com- pensate the fluid loss, Isotonic solutions are one of the best options that can be utilized with the purpose of replacement therapies (Adams et al. 2014, 338; Hinkle & Cheever 2018, 288–290). Isotonic solutions available in clinical settings are Normal saline/sodium chloride 0.9 %, Plasmalyte, Ringer, and dextrose 5 % in water or D5W (Adams et al. 2014, 339).
2.4.3 Hypotonic solutions
Hypotonic solutions have lower solute volume extracellularly but higher water as a solvent. Figure 3 illustrates the water movement from higher concentration in plasma to the cell or lower concentration.
Consequently, the cell will swell and eventually burst. (Dougherty & Lamb 2008, 71.)
ICF
Fluid shift ECF
Solutes
Smaller Plasma Volume
FIGURE 3: Movements of fluid and solution tonicity in hypotonic solutions (Modified from Adams et al. 2020, 338)
The other types of crystolloid solutions are hypotonic solutions, which are the best treatment options to modify hyperosmolar conditions especially hypernatremia and cellular dehydration. More specifi- cally, these are used to compensate intracellular fluid losses from ECF like in patients with diabetic ketoacidosis and hyperglycemia. Extreme caution is recommended regarding patients with peripheral edema and hypotension when administrating hypotonic solutions. (Hinkle & Cheever 2018, 290.) Ex- amples of hypotonic solutions are half-strength sodium chloride 0.45 % and plasmalyte (Adams et al.
2020, 339).
2.4.4 Hypertonic solutions
Hypertonic solutions can be defined as solutions with a higher concentration of solutes in extracellu- lar areas and lower water volume. This means that when the concentration of water inside cells are more than outside cell, water moves across the membrane to the interstitial space and then to the plasma. Eventually, the plasma will expand and the cell will shrink. (Dougherty & Lamb 2008, 71.) Figure 4 explains what will happen when hypertonic solutions are administered to the patient.
ICF Fluid shift
ECF
Solutes
Expanded Plasma Volume
FIGURE 4: Movements of fluid and solution tonicity in hypertonic solutions (Modified from Adams et al. 2020, 338)
These types of solutions will often be given to the patients in intensive care units. In critical situations, for example, when the serum osmolality is at dangerously low levels, hypertonic solutions like Normal saline 3 % can be given. (Adams et al. 2020, 339.) The best route of administration is through the central vein because it can be diluted by rapid blood flow. Since these solutions might cause cellular dehydration and pulmonary edema, care must be taken when administrating such solutions, especially for patients at risk for hypervolemia. (Hinkle & Cheever 2018, 290.)
3 SAFE IV-MANAGEMENT IN NURSING
In order for nurses to understand the working and functioning of fluids and electrolytes to recognise and respond to possible imbalances in a patient they need to use evidence based nursing education and knowledge. They also need to use concise and effective communication with colleagues and patients to help both prevent and/or treat various fluid and electrolyte imbalances. Nurses also have a duty of care to safely administer IV fluids to patients. (Hinkle & Cheever 2018, 252.)
This chapter looks into further detail about the safe administration of IV fluids, including the 10 rights of nurses for the administration of safe medication and it also looks at aseptic techniques. It also briefly looks at ABCDE protocol in order to assess the effects of IV fluids and medications on the patient, and the potential complications or adverse effects that can happen.
3.1 The 10 rights of medication administration
Nurses are responsible for administering medication to patients, including medicines and fluids ad- ministered via IV lines directly to the bloodstream. There is always a degree of risk involved with the process, as there are also risks involved with many other different types of nursing interventions.
(Edwards & Axe 2015, 398–406.)
Medication safety is a significant topic to learn and grasp during nursing studies because medication errors are very common and can have harmful, serious or even life threatening effects to patients.
Medication errors also have a huge economic impact on the healthcare sector. Estimates of the fre- quency of medication errors varies between 5 % - 25 % of all medication administrations. One third of all medication errors in hospitals occurs mainly in the preparation of medication and in administra- tion phase. These phases are predominantly carried out by nurses. (Smeulers, Verweij, Maaskant, de Boer, Krediet, Nieveen van Dijkum & Vermeulen 2015, 1–14.) To ensure safe drug administration and in order to prevent any harm or injury to the patient, nurses are encouraged to follow the ‘10 Rights’
to prevent errors in administration of medications. These 10 rights are the right patient, the right drug, the right dosage, the right time, the right route, the right to refuse, both the patient and the nurse, the right education, the right documentation, the right assessment and the right evaluation.
(Edwards & Axe 2015, 398–406.) Further information for each right is given in Table 2.
TABLE 2: The 10 rights for safe multidisciplinary drug administration (modified from Edwards & Axe 2015, 398–406)
No. Rights Information / Considerations
1 Right patient Check that the patient is the correct patient. Ask their name and social security number and dou- ble check against their wristband. Consider whether the patient has been prescribed the drug and consider whether the patient knows (a) that they are receiving the medication and (b) why.
Check the name on the prescription.
2 Right drug The prescription of the drug should be clear on the patients record and easy to read. Consider that the drug chosen IS the correct drug and not a drug with a similar name. If necessary, ask another nurse or health professional to check the drug. Check the expiry date. Make sure medi- cations, especially antibiotics, are reviewed regularly.
3 Right dosage Check the prescription. Consider whether the dose of the drug seems appropriate or unusual for the prescribed medication using BNF or local guidelines. Double check the drug calculation with another nurse or healthcare professional to remove doubt and ensure that no error has been made.
4 Right time and frequency
A drug needs to be administered at the appropriate time for effective outcomes, for example, antibiotics. Check the frequency of the prescribed drug. Consider the time gap between each drug administration – has it been adequate, too long or too short? Confirm when the last dose was given.
5 Right route Some drugs cannot be administered via the oral route. Others can only be administered IV via the central vein as opposed to the peripheral vein. Check the drug order and appropriateness.
Confirm that the patient can take the drug by the ordered route.
6 Right to refuse (both patient &
nurse) & drug approach
Consider whether you know how to prepare and administer the medication in line with policies.
Ensure the patient consents to medication being administered. Consider whether you as a nurse can exercise your clinical judgement and refuse to give or to omit the drug. Do you have good reason for this, and can this be explained to others? Consider what to do if the patient refuses to take the medication and how to respond as patients (with full capacity) have the right to refuse medication.
7 Right education
Provide enough knowledge to the patient of what drug they are taking and what are the thera- peutic, adverse effects and interactions of this medication? Does the patient know about the drug and what it is for, its effects, how long it lasts in the system, its most common side effects?
Make the patient aware to contact a health professional if they experience side effects or ad- verse reactions.
8 Right documen- tation
Make sure to document the time and route that the drug is given on the care plan correctly. Is the prescription written clearly and understandable to those administering the drug? Does it have a start and end date? Consider whether you can communicate with other professionals if needed and whether there is access to available resources, for example, Duodecim or Lääkeinfo, to further read up about the drug.
9 Right Assess- ment
Secure a copy of the patient’s medical history to previous drug interactions and allergies. Check for contraindications. Observe & monitor vital signs if necessary
10 Right evaluation Ensure the medication is working the way it should. Continue to observe vital signs. Consider whether you know the expected response or outcome of the drug, and if in an instance of an al- lergic reaction or anaphylactic shock you know how to act in the situation and how to call for help or emergency assistance. Consider whether you know how and when to complete docu- mentation and administration records in regards with local policies and how to fill in a HaiPro re- port if there are mistakes or errors.
3.2 The importance of aseptic techniques
In addition to the 10 rights of medication administration, nurses also have an important responsibility to administer medications aseptically. Asepsis means the absence of bacteria, viruses, and other mi- croorganisms. Aseptic technique is a method of maintaining asepsis and an effort to keep patients as free from exposure to infection-causing pathogens as possible. Adhering to good practice in infection control principles and maintaining aseptic techniques during IV fluid therapy is a vital and essential clinical skill. Aseptic technique is an important competence required by healthcare workers in order to prevent healthcare-associated infections, HAI, in patients. (Boyd 2014, 8; Brady, McCabe & McCann 2014, 168; Potter & Perry 2015, 243; Clare & Rowley 2018, 6–15.)
The insertion of a peripheral vascular catheter, PVC, into a vein, provides a potential portal of entry for bacteria to cross from an unsterile environment directly into the bloodstream, which is classed as a sterile area. Aseptic techniques when cannulating a patient, and during the administration of IV fluids, is key in order to reduce the risk of transmitting bacteria, microbes or pathogens from the healthcare worker´s skin or from the external surrounding environment to the patient. Good aseptic technique is maintained by good hand hygiene, with hand-washing and use of hand disinfectant, and the use of sterile gloves during the IV catheter placement procedure. Aseptic techniques also include the care and maintenance of the PVC as the PVC insertion site is classed as a wound, therefore it is important to keep the insertion site covered, clean and dry in order to offer protection from any external contaminants. (Zhang, Cao, Marsh, Ray-Barruel, Flynn, Larsen & Rickard 2016, 208-211;
Potter & Perry 2015, 262.)
3.3 Nursing Interventions – ABCDE
In nursing science, the mnemonic “ABCDE” stands for Airways, Breathing, Circulation, Disability, and Exposure. The ABCDE approach is a systematic and logical step-by-step approach for the immediate assessment, evaluation, and treatment of patients, ensuring that the vital signs are investigated.
ABCDE is carried out on all patients whether as an emergency intervention for critically ill or injured patients, or as a nursing intervention to monitor patients during ongoing continuous hospital treat- ment. The ABCDE approach is therefore used as a comprehensive nursing intervention to monitor patients who are receiving medications and IV fluids. (Thim, Krarup, Grove, Rohde & Løfgren 2012, 1-5; Guest 2020, 1-6.) In Table 3 each part of the ABCDE process and the assessment that needs to be made is listed in more detail.
TABLE 3. The ABCDE Assessment Tool (Modified from Thim, Krarup, Grove, Rohde & Løfgren 2012, 1-5)
ABCDE Assessment
Airways Is the airway clear? Can the patient speak? Breath sounds, Breath movements
Breathing Respiratory rate (12–20 min), Respiration pattern, Chest wall movements, SpO2 (97%–100%), Lung sounds, Colour of the patient (i.e. cyanosis)
Circulation Pulse rate (60–100 min), Blood pressure (systolic 100–140 mmHg), Skin colour, sweating, Capillary refill time (<2 s),
Disability Level of consciousness – AVPU - Alert, Voice responsive, Pain responsive, Unresponsive Limb movements, Pupis, Pain, Blood sugar, Glasgow Coma Scale
Exposure Perform head to toe examination, front to back. Expose the skin, Check the skin colour, Check for signs of rash, Check skin temperature, Are there cold or clammy skin areas?
During IV fluid therapy, the ABCDE approach is not only used as an initial assessment tool before starting the treatment but it is also an ongoing nursing responsibility as regular assessments need to be made in order to ensure patient safety to avoid potential risks and complications. It is also im- portant to monitor the IV site for signs and symptoms of infection. (Spencer & Gilliam 2017, 64; Guest 2020, 1–6.)
3.4 Nursing management with systematic and local complications of IV fluid therapy
Nurses must know how to manage possible systematic or local complications for a patient receiving intravenous therapy. Nurses also need to know how IV infusions impact total body fluid volume and try to avoid possible complications like unwanted fluid shifts and alterations. Depending on the types of complications, nurses must have adequate knowledge and skill to handle the situation. First, it is important to identify the types of complications, signs and symptoms, risk factors, causes, and then in practice, try to avoid and minimize hazards. Even if in clinical settings we encounter complications, it is an expected skill for nurses to apply nursing management based on organizational policies, pro- cedures, and regulations. (Hinkle & Cheever 2018, 290.)
Fluid overload is one of the most common systematic complications. It happens when excessive IV fluid enters into the circulatory system causing increased blood pressure and central venous pressure.
Some of the signs and symptoms are dyspnea, edema, weight gain, and rapid, shallow respiration. It might happen as a result of a medical error, for example a rapid IV infusion, or due to cardiac or renal disorders. In the case of circulatory over-fluid, patients could be susceptible to pulmonary edema or heart failure. Using an IV-pump, carefully monitoring vital signs and assessing breath sounds regularly are considered good prevention techniques. For patients with this problem, it is important to reduce the IV rate and put the patient into a high Fowler position. (Qamar, Afzal, Kousar, Waqas & Gilani 2017, 610.)
Other systematic complications are infections, and in rare cases, air embolisms. The risk of infection could be in association with either an infusion solution or IV administration set. Prevention of infection is possible with aseptic methods, see part 3.2. Infection is evidenced by hyperthermia, headache, tachycardia, and increased respiratory rate. In severe cases, septic shock might also happen. (Hinkle
& Cheever 2018, 290-291.)
Local complications include infiltration and extravasation, hematoma, phlebitis, which means inflam- mation of the vein, and thrombophlebitis, which is defined as the presence of a clot in addition to inflammation of the vein. Infiltration means the administration of medicine or fluids into the tissue surrounding the venipuncture site due to the inappropriate cannulation technique. It is easily distin- guishable when signs and symptoms appear such as edema, leaking of fluid from the insertion site and coolness of the area. (Qamar et al. 2017, 609.)
To prevent any local complications, it is recommended to do close monitoring of the IV site in order to detect the complication early enough and prevent further injuries. Relying on the types of local complications nurses will apply different interventions. However, in all types stopping the infusion, discontinuing the IV catheter and IV line are common. (Hinkle & Cheever 2018, 291-293.)
4 ADULT LEARNERS
The following text gives a short theoretical background to the adult learning theory, or andragogy. It also talks about the virtual learning environment & PowerPoint and provides information about testing knowledge.
4.1 The adult learning theory
The concept of adult learning theory or andragogy refers to the art and science of teaching an adult.
The term ‘adult’ can be defined in four aspects such as biological, legal, social, and psychological. In regard to adult education, the psychological aspect of adult’s definition which means being self-direct- ing is most crucial. (Knowles, Holton & Swanson 2005, 61–64.)
It is also worth highlighting the differentiation between pedagogy and andragogy. Pedagogy is a field of study concentrating on the children learning and its theory emerged earlier than andragogy. In the andragogical model, the difference between the characteristics of adult and children learners have been addressed in several assumptions. (Knowles et al. 2005, 61–68.) These assumptions are the sense of need and independency that adult learners set their learning goals based on their needs before undertaking to learn it. The assumptions also factor in that the feeling of responsibility towards learning is meaningful for adults, leading to accountability and self-concept in learning and that there is an adult learner experience based on the fact that each adult learner has a huge learning experience in their background. The assumptions also include that there is a readiness to learn and that adults should keep up with new situations, and that there is orientation of learning so that learning is useful for adults to encounter new challenges in life. The differentiation between adult and children charac- teristics of learning is that there is motivation to learn as the adult learners know their primary goals towards learning. (Spies, Seale & Botma 2015, 1–2.)
4.2 Virtual learning environment and PowerPoint
A virtual learning environment or VLE is an internet-based platform providing digital learning materials for courses to study. It consists of multiple information and communication technologies (ICT) that are integrated into one system. While there is no one-size-fits-all formula for the design of a VLE, it is widely discussed that it develops an individual learner’s knowledge, skill, and performance in differ- ent ways. One evident benefit of having E-E-learning is that learners are allowed to attend the courses regardless of their geographical locations. In other words, distance learning helps adult learners to set their learning goals based on their individual needs and learning styles. In addition to flexibility for the learners, it worth mentioning that it has been proved that learning in a VLE has a significant effect on adult learning’s motivation, which is one of the assumptions of the andragogical model. (Bashshar 2017, 1–10.)
On the other hand, studies have shown that adult students feel disconnected from their learning environment associated with studying online. The reasons could be, for instance, poor design and usage of the VLE in educational organizations, in other words poor understanding of applying ICT in web-based learning to create a collaborative learning environment. Another argument towards VLE is also a lack of adequate social interactions, however, social integration is an important element in the
adult learning process. Overall, these could contribute to a lower level of motivation for learners and may lead to receiving poor learning results and eventually organizational failure. Therefore, it is es- sential to utilize multi-purpose learning methods in designing a learning platform for adult learners.
(Bashshar 2017, 3–4.)
One of the most popular teaching methods which can be used in VLE is PowerPoint (PPT). There are several reasons why people decide to use PowerPoint in lectures and presentations. PPT provides a planned structure for developing a presentation. Using PPT provides the lecturer/speaker with a framework and outline to clearly teach a topic. A point to consider with PowerPoint is “What makes a good PPT presentation?” . The educational psychologist Richard Mayer (1992) has done much re- search on the effects of learning on students’ retention of a topic when using PPT or multimedia. His theory of multimedia learning states that ‘‘meaningful learning occurs when learning engages in ap- propriate verbal and visuospatial thinking’’ (Mayer R 1992, 55–71.) It is useful to learn and know what kind of materials can be used to make learning more interactive for adult students. By using a variety of relevant images within the PPT this can aid the students learning. Images are better than a lot of in-depth text, by not using too many bullets & limiting the amount of information on one slide and by using interesting multimedia presentations within the PPT but avoiding excess. (Penciner 2015, 111.) The best teaching styles for topics like fluid therapy suggested by experts is using a combination of strategies including contact lessons, workshops, interactive practice activity lessons such as skill labs along with e-learning courses, and virtual learning materials. The effect of VLE on nursing students’
learning process has been discussed in many studies. The results indicated that students using virtual simulations or E-learning compared with those who are just being taught with traditional teaching methods like lectures and training on the anatomical have had a better performance and progress.
Thus, VLE is considered an effective model to teach. (De Souza-Junior et al. 2020, 24–30.)
Based on the findings of the thesis study, another important influential factor that could enhance the success of the education strategies and meet the course objectives that needs to be considered by educating providers is bearing in mind the participants´ level of study: whether they are second-year nursing students or graduated nursing students. (De Souza-Junioret al. 2020, 30.)
4.3 Testing knowledge
Self-Determination Theory (SDT) is presenting a student-centered learning approach where adult learners are involved in learning sessions from the start to the end. In this theory, learners are allowed to manage their own learning goals and make individual learning content. To design a successful online learning material the following factors are to be considered: feedback, choice, competence, challenge, interest, relevance, collaborations, and instructor’s role in online discussions. They all have a significant impact on the learner’s motivation. (Bashshar 2017, 18-20.)
Studies have been conducted in assessing online learning. In summary, based on the educator's and course objectives, there are three types of assessments: diagnostic, formative, and summative. Diag- nostic assessment concentrates on students´ prior knowledge. It is not graded, and it leads instruc- tions. Examples of diagnostic assessments are student surveys and pre-tests. Formative assessment is an ongoing means throughout a course. The goal of formative assessment is to guide teaching and improve the learning process. Both formal and informal types of this assessment are graded and feedback on student participation is recommended. A summative assessment is used at the end of the course to evaluate the students´ performance and knowledge in grade or score. In fact, it shows course accomplishments, which means whether the students have met the course objectives or not.
A culminating project, performance task, test, or a final exam are examples of summative assess- ments. (Orlando 2011, 7.)
