WARD CLASS
By: Jennette O. Zambales
BSN4-F
LEARNING OBJECTIVES
After the discussion, learners are expected to be able
to:
Identify different types of IV solutions.
Perform hand hygiene correctly.
Solve the IV flow rate.
Regulate IV accurately.
Formulate nurses notes comprehensively.
TOPICS
TYPES OF IVF Removing Foley
Catheter
IVF Calibration,
Regulating IVF Applying
, Following up abdominal binder
an IVF and Wound
Removing an dressing for
IVF post CS
FDAR charting
TYPES OF IV SOLUTIONS
ISOTONIC SOLUTION
Same or equal osmotic pressure inside and
outside of the cell
Isotonic solutions don’t cause fluid shift inside
or outside of the cell it keep the cells balance
ISOTONIC SOLUTIONS:
0.9% Normal Saline(NS)
Lactated Ringer(LR)
5% Dextrose in Water in the
bottle/bag (D5W)
HYPOTONIC SOLUTION
Hypotonic solution have more
water than solutes(compared
to isotonic)
Fluid will move INTO cells so
they SWELL the cells
HYPOTONIC SOLUTIONS
0.45% Sodium Chloride (0.45% NaCl)
0.225% Sodium Chloride(0.225% NaCl)
5% Dextrose in Water in the body (D5W)
HYPERTONIC SOLUTION
Hypertonic solution have more
solutes than water(compared
to isotonic)
Fluid will move OUT of the cell
so the cells will SHRINK
HYPERTONIC SOLUTIONS
3% Sodium Chloride (3% NaCl)
5% Dextrose and 0.45% Sodium Chloride
(D50.45% NaCl)
5% Dextrose and Lactated Ringer’s (D5LR)
10% Dextrose in Water D10W
IVF Calibration, ReguLating
IVF, Following up an ivF and
Removing an IVF,
Calculating flow rate
IV Tubing Calibration
The size of a drop in an IV setup depends upon the width of the IV tubing: thinner
tubing produces smaller drops and wider tubing produces larger ones. IV tubing
is pretty standard, and so there are two major categories of IV tubing:
TWO TYPES OF IV TUBING
TWO TYPES OF IV TUBING
Macrodrip tubing is wider and so produces
larger drops. It is the tubing most commonly
used for routine IV administration, such as
infusion of IV fluids that do not contain
sensitive medication.
Macrodrip tubing comes in 3 sizes: 10
gtts/mL, 15 gtts/mL and 20 gtts/mL.
TWO TYPES OF IV TUBING
Microdrip tubing is narrower and so
produces smaller drops. It is used for
children and infants, or to infuse
sensitive medications where precision
in the flow rate is essential.
Microdrip tubing (sometimes called
minidrip) comes in only one size: 60
gtts/mL.
CALCULATING IV FLOW RATE
To set up a IV, we need to know the flow rate; the flow rate is the speed at
which the fluid infuses into the patient, and it is expressed in volume over
time.
FORMULA:
Volume(mL)
X Drop factor(gtts/ml) = Flow rate (gtts/min)
Hours to run(in min)
To get the mL/hr:
Volume(mL)
= mL/hr
Hours to run
Let’s Solve
The patient needs 1,000 mL of saline IV over 6 hours for a patient with deficient fluid
volume. How many milliliters per hour will you regulate?
Where:
Total infusion volume (mL) = 1,000 mL
Total infusion time = 6 hours
Computation:
1000ml
6 hours
= 166.66 or 167 mL/hour
Let’s Solve
Solve for the flow rate
Drop factor of 20gtts/mL
Convert hour into minutes
1hr = 60 mins
6x60= 360mins
1000ml
360mins
x 20gtts/mL
=55.55 or 56gtts/min
Let’s Solve
Solve for the hours to run
A patient is ordered to received 1,000 mL of NSS to be administered at 125 mL/hour.
How many hours will pass before you change the IV bag?
Where:
Total volume to infuse = 1,000 mL
mL infused per hour = 125 mL/hour
Calculate:
1000mL
125mL/ hour
8 hours
Let’s Solve
One liter of Normal Saline is charted over 9 hours. The
drop factor is 15.
Calculate the mL/hour and the number of drops per
minute.
Removing foley catheter
Removing an Indwelling Catheter
Purposes:
1. Terminates urinary catheterization
2. Permits return of client-controlled voiding
EQUIPMENTS:
Syringe (appropriate size to remove water from balloon on catheter)
Graduated container
Pair of clean gloves
Basin of warm water
Soap
Washcloth
Towel
Linen saver
Assessment
Assessment should focus on the following:
Length of time catheter has been in place and agency policy regarding maximum
length of time before catheter removal or change
Order for catheter removal and parameters for removal (e.g., after specimen
obtained, when client is ambulatory)
Client's knowledge of catheter removal procedure
Size of catheter and balloon
Characteristics of urine (e.g., color, clarity, odor, amount)
Amount of urine output
Distention, pain, or tenderness of lower abdomen
STEPS RATIONALE
1. Explain procedure to Promotes cooperation and decreases
client. anxiety
2. Provide privacy. Protects client's dignity and
decreases embarrassment
3. Apply nonsterile gloves.
Reduces nurse's exposure to client's
body secretions
4. Place client in supine or lateral
Provides access to catheter and
position, and place linen saver
prevents soiling linens
under client's buttocks.
Continue...
Permits removal of sterile specimens
5. Obtain urine specimen if ordered. before loss of access
6. Insert syringe into balloon port inflation Provides access to remove water from
valve. the balloon to deflate it
7. Aspirate total amount of fluid that was
Fully deflates balloon to prevent damage
used to inflate the balloon. If unsure if
to urethra during removal process
balloon is fully deflated, cut the inflation
port and allow water to drain.
8. Remove tape or catheter holder.
Allows removal of catheter
Continue...
9. instruct client to relax and take slow Promotes relaxation of sphincter
deep breaths. Slowly and smoothly pull muscles; prevents trauma to
catheter out onto towel. urethral mucosa
10. Hold catheter up until urine has Permits collection of urine and
drained into bag. prevents
11. Measure amount of urine in collection
Provides assessment data;
container or drainage bag, noting color
decreases exposure to body waste;
and consistency of urine, and discard
properly disposes of contaminated
catheter and drainage bag by wrapping
substances
them in a linen saver.
Continue...
12. Position client for comfort Promotes clean environment
and discard all disposable
equipment with gloves.
13. Perform hand hygiene. Reduces microorganism transfer
14. Instruct client to notify Allows nurse to assess ability to
nurse of next voiding and to void after catheter removal
save urine.
Documentation
The following should be noted on the client's chart:
Assessment of lower abdomen before removal of catheter
Assessment of genitalia, if abnormalities noted
Size of catheter
Amount, color, and consistency of urine draining from catheter
Any difficulties encountered when removing catheter
Reports of unusual discomfort during removal
Status of catheter
Time and amount of first voiding
Specimen obtained (catheter tip sent to lab, if applicable)
Abdominal binder
Charting FDAR/Focus Method
PURPOSE:
1. Facilitates comprehensive communication of relevant client data from one nursing
caregiver to other nurses or memnbers of health care team
GENERAL GUIDELINES:
Must be evident at least once every shift
Must be patient- oriented nit nursing task oriented.
Indicate the time and date on the first column.
Separate the topic words from the body of notes.
Sign name for every entry.
Document only patient's concern or plan of care.
Document patient's status on admission for every transfer to/from another unit or
Discharge.
Follow the Do's of documentation.
Elements of Focus Charting:
FOCUS DATA
ldentifies the content of
the narrative entry. Is the subjective and/or
Separated from the body objective supporting the
of the notes in order to stated focus or describing
promote easy data the observation at the
retrieval a time of a significant event.
communication.
Elements of Focus Charting:
ACTION RESPONSE
Include immediate Describe the patient's
interventions performed, response to any aspect of
planned/future nursing medical or nursing care
actions or your Statement that the action
assessment of the plan of care outcomes have
patient's condition. been attained or are
progressing toward.
