fundamental

2. Medication and fluid therapy
• A drug is a substance that changes the function of a living organism in some
way.
• Drugs can be used for pleasure (recreational) or as treatment.
• A drug that is used for a therapeutic purpose is called a medication.
• Medications are used to diagnose, prevent, and treat various illnesses.

3. CHANNELS OF
DRUG
ADMINISTRATION
ENTERAL PARENTERAL TOPICAL

4. General Guidelines for Safe Medication Administration
• Wash your hands.
• Prepare medications in a well-lit area.
• Always check medication label against order three times (name,
dosage strength, route and form, and so on).
• Always check for allergies.
• Consistently follow the six rights of medication administration.
• Give only medications prescribed by a legally authorized person.
• Only give medications you have prepared; do not leave medications
unattended.

5. General Guidelines for Safe Medication Administration
• Never give a medication with an altered appearance.
• Never give a medication that you have concerns about (better to be
safe than sorry; check with the pharmacist or prescriber).
• Shake medications if required.
• Measure medications at eye level.
• Use universal precautions and sharps precautions as appropriate.
• Safely store medications (separate look-alike, sound-alike
medications; label high-alert medications).
• Avoid taking short cuts and performing work-arounds.
• Always be honest!

6. Cont.…
Handling Medication Errors
• Recognize the error.
• Stay calm.
• Report the error immediately.
• Follow the prescriber’s orders for correcting the error.
• Document the error according to organizational policy (usually on
an occurrence report, not the nurse’s notes).

7. Nurses play a critical role in the medication administration process.
• Although medication administration is a part of the nurse’s daily routine, it
is far from being a routine skill.
• Medication administration requires knowledge of basic pharmacologic principles,
legal requirements, and medication administration principles.
• Critical thinking along with the nursing process provides for a safe, effective,
systematic approach to medication administration.
• A review of the medication rights (right patient, right medication, right dose,
right route, right time, and right documentation) should always be included
during medication administration.

8. • Medication actions and effects are influenced by how the medication is absorbed, distributed,
metabolized, and excreted by the body.
• Medications have intended effects and unintended effects.
• The goal of medication therapy is that the patient receives medications that provide the best
benefit without unintended effects or with minimal unintended effects.
• The nurse provides valuable information to the prescriber for the determination of how this
balance can best be achieved.
• The nurse is totally accountable for his or her actions as it relates to medication administration,
including responsible reporting of medication errors in a timely manner so as to ensure the
safety of the patient.

9. FLUID THERAPY
• It is administration of large amount of solution / fluid in
to circulatory system through vein.
• Intravenous fluids are similarly classified based on their
ability to pass through capillary walls that separate the
intravascular and interstitial fluid compartments into
Crystalloid fluids and Colloid fluid .

10. Cont.…
• Crystalloid fluids are electrolyte solutions with small molecules
that can diffuse freely from intravascular to interstitial fluid
compartments
• Colloid fluid is a saline solution with large solute molecules
that do not pass readily from plasma to interstitial fluid.
• The retained molecules in a colloid fluid create an osmotic
force called the colloid osmotic pressure or oncotic pressure
that holds water in the vascular compartment.

11. The aims of IV fluid administration should be to
• Avoid dehydration
• Maintain an effective circulating volume
• Prevent inadequate tissue perfusion during a period when the patient is
unable to achieve
• These goals through normal oral fluid intake
• “Intravenous fluids have a range of physiologic effects and should be
considered to
• be drugs with indications, dose ranges, cautions, and side effects.”

12. CLASSIFICATION
I V Fluids
Blood and Products Non blood I V Fluids
Crystalloids
•Glucose Containing
•Electrolyte
solutions
•Mixed
Colloids
Proteinous Non proteinous
Gelatins
• Haemaccel
• Gelofusin
Albumin
20% & 5%
Starch Dextrans
 HES
 PentaStarch
 Tetrastarch

13. CRYSTALLOIDS
• Crystalloid are electrolyte solutions with small molecules that
can diffuse freely from intravascular to interstitial fluid
compartments.
• The principal component of crystalloid fluids is sodium chloride.

14. CRYSTALLOIDS
HYPOTONIC ISOTONIC HYPERTONIC IONIC NON-IONIC
• D5W
• ½ NS(0.45%)
• NS
• RL
• Plasmalyte
• Hypertonic
saline
• 10%, 25% &
50% dextrose.
• NS
• Dextrose saline
(DNS)
• Ringer’s lactate
• 5% Dextrose
• 25% Dextrose

15. NORMAL SALINE
• One of the most commonly administered crystalloids
• Composition
• Na-154 meq/l
• Cl- 154 meq/l
• pH- 5.7
• hence it affects the acid base balance of the body
• Pharmacological basis
1. Provide major extracellular electrolytes.
2. Corrects both water and electrolyte deficit.
3. Increase the intravascular volume substantially.

16. Indications
• To maintain effective blood volume and blood pressure in emergencies
• Water and salt depletion – diarrhea, vomiting, excessive diuresis or
excessive perspiration
• Hypovolemic shock- distributed in extracellular space expanding the
intravascular volume. Ideal fluid to increase blood pressure.
• Preferred in case of brain injury, hypochloremia metabolic alkalosis ,
hyponatremia
• Initial fluid therapy in DKA

17. • In patients with hyperkalemia like renal failure
• Hypercalcemia
• Fluid challenge in prerenalARF
• Irrigation for washing of body fluids
• Vehicle for certain drugs

18. Contraindications
• Avoid in Hypertension, Preeclampsia and in patient with edema due to CCF, renal
failure and cirrhosis
• In dehydration with severe hypokalemia – deficit of intracellular potassium because
of infusion of NS without additional K+ supplementation can aggravate electrolyte
imbalance
• Large volumes or too rapid administration can cause sodium accumulation and
pulmonary edema.
• Increased chloride content in relation to plasma can cause hyperchloremic
• metabolic acidosis in large volume administration

19. RINGER’S FLUIDS
• A solution that contained calcium and potassium in sodium chloride
solution to promote cardiac contraction and cell viability.
• Ringer`s lactate is the most physiological fluid as the electrolyte
content is similar to that of plasma .
• Larger volumes can be infused without the risk of electrolyte imbalance
• Due to high Na ( 130mEq/L) content RL rapidly expands intravascular
volume effective in treatment of hypovolemia.

20. • Composition
• Sodium:131meq/l
• Potassium – 5meq/L
• Bicarbonate – 29 meq/L
• Chloride – 111meq/L
• Calcium – 2meq/L
• Each 100 ml contains
• sodium lactate - 320mg
• NaCl - 600mg,
• KCl- 40mg
• CaCl- 27mg

21. Indications
• Correction in severe hypovolemia
• Replacing fluid in post operative patients, burns , fractures.
• Diarrhea induced hypokalemic metabolic acidosis and hypovolemia.
• Fluid of choice in diarrhea induced dehydration in pediatric patients.
• In DKA,provides glucose free water, correct metabolic acidosis and supplies
potassium
• Maintenance fluid during surgery

22. Contraindications
• Severe liver disease, severe hypoxia , shock – impaired lactate metabolism –lactic
acidosis.
• Severe CHF - lactic acidosis takes place.
• Addison’s disease
• In vomiting or continuous nasogastric aspiration, hypovolemia is associated with
metabolic alkalosis - as RL provides HCO3- Worsens alkalosis.
• Simultaneous infusion of RL and blood- inactivation of anticoagulant by binding
with calcium in RL – clots in donor blood.
• Certain drugs – amphotericin, thiopental, ampicillin, doxycycline should not be
mixed with RL – calcium binds with these drugs and reduces bioavailability and
efficiency

23. DEXTROSE SOLUTIONS
• D5 water (5%D)
• Dextrose with 0.9% NS ( DNS ).
• Dextrose with 0.45% NS (D 1/2NS )
• 10% dextrose
• 25% dextrose
• EFFECT OF DEXTROSE IN FLUID :
 Protein sparing effects
 Volume effect
 Lactate production.
 Effect of hyperglycemia

24. Protein sparing effect
• Earlier it was used to provide calories in patients who were unable to
eat
• 50 grams of dextrose per liter provides 170 kcal
• Infusion of 3 liters of a D5 solution daily (125 mL/min) provides 3 x
170 = 510 kcal/day, which is enough nonprotein calories to limit the
breakdown of endogenous proteins to provide calories (i.e., protein-
sparing effect)

25. Volume Effects
5%D
• 50 g of dextrose adds 278 mOsm/L to IV fluids
• For a 5% dextrose the added dextrose brings the osmolality close to that of
plasma.
• However, dextrose is taken up by cells and metabolized, this osmolality effect
rapidly wanes, and the added water then moves into cells.
• The infusion of one liter of 5D results in an increase in ECF (plasma plus
interstitial fluid) of about 350 mL, which means the remaining 650 ml (two-
thirds of the infused volume) has moved intracellularly.
• Therefore, the predominant effect of D5W is cellular swelling.

26. DNS
• Total osmolality of DNS fluid is 560 mOsm/L (278 of dextrose and
308 0f 0.9 NaCl) which is almost twice the normal osmolality of the
extracellular fluid.
• If glucose utilization is impaired (as is common in critically ill
patients), large-volume infusions of D5W can result in cellular
dehydration

27. Enhanced lactate production
• In healthy individuals 5% of infused glucose is directed towards lactate
formation.
• In critically ill patients 85% of glucose is diverted to lactate production.
• when circulatory flow is compromised, infusion of 5% dextrose
solutions can result in lactic
• acid production and significant elevations of serum lactate

28. Hyperglycemia
It has several deleterious effects in critically ill patients including –
 immune suppression .
 increased risk of infection
 aggravation of ischemic brain injury Considering the high risk of
hyperglycemia in ICU patients, and the numerous adverse
consequences of hyperglycemia, infusion of dextrose containing
fluids should be avoided whenever possible.

29. 5 % DEXTROSE
Composition : Glucose 50 gms/L + free water
Pharmacological Basis
•Corrects Dehydration And Supplies Energy ( 70kcal/L)
•Administered safely at the rate of 0.5gm/kg/hr. without causing glycosuria
Metabolism
 Dextrose is metabolized leaving free water distributed in all compartments of the body.
 A proportion of dextrose load contributes to lactate formation –
 5% in healthy subjects
 85% in critically ill patients
 hence not the preferred fluid.

30. Indications of 5%D
• Prevention and treatment of intracellular dehydration
• Cheapest fluid to provide adequate calories to body
• For pre and post operative fluid management
• IV administration of various drugs
• Treatment and Prevention of ketosis in starvation, vomiting, diarrhea
• Adequate glucose infusion protects liver against toxic substances.
• Correction of hypernatremia due to pure water loss ( Diabetes insipidus)

31. Contra indication
1. Neurosurgical procedures - can aggravate Cerebral oedema and increase ICT
2. Acute ischemic stroke-
• hyperglycemia aggravates cerebral ischemic brain damage.
• Dextrose metabolism aggravates tissue acidosis in ischemic areas- anerobic
oxidation of glucose produces more lactic acid and free radicals
3. Hypovolemic shock
• Poor expansion of intracellular volume.
• Faster rate of infusion causes osmotic diuresis  worsens shock and false
impression of the hydration status  reduced fluid replacement.
4. Hyponatremia & water intoxication - 5%D worsens both conditions

32. 5.Hypernatremia – fast infusion of 5D rapidly corrects hypernatremia but
correction occurs slowly in brain cells, so swelling of brain cells can
lead to permanent neurological damage. Moreover rapid infusion of 5D
induces osmotic diuresis which aggravates hypernatremia
6. Can cause Hypokalemia, hypomagnesemia and hypophosphatemia
7. Bloodand dextrose solutions should not be administered in same IV
line – hemolysis , clumping seen due to hypotonicity of the solution.
8. Uncontrolled DM , severe hyperglycemia

33. DEXTROSE SALINE (DNS)
Composition
• Na- 154 mEq/L
CI- 154mEq/L
• Glucose- 50 gm/L
Pharmacological basis
• supply major extracellular electrolytes, energy and fluid to correct dehydration
• In presence of incompletely or partially corrected shock patient will have increased
urine output (due to diuresis)
• Unlike 5D, DNS is not hypotonic (due to Nacl) and hence it is compatible with blood
transfusion

34. Indications
• Conditionswith salt depletion and hypovolemia not the ideal fluid
though.
• Faster rate of infusion causes osmotic diuresis. worsens shock and false.
• impression of the hydration status reduced fluid replacement
• Correctionof vomiting or nasogastricaspiration induced alkalosis and
hypochloremia along with supply of calories

35. contra indication
• Anasarca – cardiac, hepatic or renal cause
• Severe hypovolemic shock – rapid correction is needed. Faster infusion
can cause osmotic diuresis and worsen the condition.

36. DEXTROSE WITH HALF STRENGTH SALINE
•Composition : 5% dextrose with 0.45% NS NaCl – 77 meq/L each,
glucose 50 gm/L
• Contains 50% salt as compared to DNS /NS and used when there is
need for calories , more water and less salt.
•Indications
1. Fluid therapy in pediatric – In pediatric group ratio of requirement of
water : NaCl is double as compared to adults
2. Treatment of severe hypernatremia It corrects
hypernatremia gently, it avoids cerebral edema
3. Maintenance fluid therapy and in early post operative period.
•Contra indication
4. Hyponatremia
5. Severe dehydration where larger salt replacement is needed

37. 10%DEXTROSE &25% DEXTROSE
Composition
Pharmacological basis:
• It is hypertonic crystalloid fluid
• Supplies energy and prevents catabolism useful when
faster replacement of glucose is
• needed like in Hypoglycemic coma
• In patients with fluid restriction- CCF, Cirrhosis and Renal
failure

38. Indications
• Rapid correction of hypoglycemia .
• In liver disease, if given as first drip, it inhibits glycogenolysis and
gluconeogenesis
• Nutrition to patients on maintenance fluid therapy.
• Treatment of hyperkalemia with Insulin

39. Contra indication
• In patients with dehydration, anuria, intracranial hemorrhage and in
delirium tremens.
• Avoided in patients with diabetes unless there is hypoglycemia.
• Rapid infusion of 25D can cause glycosuria.
• Hence the absence of in hypoglycemia it should be infused slowly over
45 - 60 min.
•