Long-Term Care

Intravenous therapy guidelines

LTC Nursing Assistant Trainer, May 3, 2012

Before initiating intravenous therapy, perform a focused assessment of the resident’s hydration status. If the resident is receiving the IV for antibiotics, also assess the condition for which antibiotics are being given. At a minimum, assess:

  • Vital signs
  • Skin turgor
  • Mucous membranes
  • Total body weight; history of recent loss or gain

-Loss or gain of one kilogram of body weight is reflective of a loss or gain of 1 liter of fluid

  • Signs and symptoms of dehydration:

-1% fluid loss: Thirst
-2%–5% fluid loss: Dry mouth, flushed skin, weakness, impaired physical ability, fatigue, headache
-6% fluid loss: Increased temperature, pulse, respirations, increased weakness, dizziness
-8% fluid loss: Labored respirations on exertion, increased weakness, dizziness
-10% fluid loss: Delirium, swollen tongue, muscle spasms
-11% fluid loss: Failing kidney function, poor blood circulation

  • Peripheral veins for assessment of plasma volume

-Elevate the hand; the veins should empty within three to six seconds
-Lower the hand; the veins should fill quickly

  • Fill times as high as 10 seconds suggest sodium depletion
  • Urine volume and specific gravity

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

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