Management of Dehydration: Fluid Bolus Therapy (Nursing)

00:01 We're going to talk about one of the interventions that you will probably be performing as a nurse and that is giving a fluid bolus.

00:09 So giving an IV bolus is something that you will do if you have a patient that has low fluid volume or is dehydrated.

00:18 And if you remember from a previous presentation, there are several types of dehydration.

00:24 We have hypotonic dehydration, isotonic dehydration, and hypertonic dehydration.

00:31 Now, what these all have in common is that you will need to perform some fluid repletion.

00:37 And that just simply means that you're going to have to give fluid back to the patient.

00:44 So, we'll talk through in this presentation some of the important considerations that you should be thinking about as you're giving a fluid bolus.

00:53 First, we're going to talk about how you can understand the indication for the fluid bolus itself.

01:02 So, when you have a pediatric patient that is dehydrated, you are probably going to be giving a fluid bolus if you have moderate to severe hypovolemia.

01:12 And what this means is that that patient does not have enough fluid rolling around in those blood vessels to keep up a good blood pressure.

01:21 So they really are out of fluid deficit.

01:25 This can really be evidenced by hemodynamic changes, and what you're probably first going to notice is that heart rate is really going to start shooting up.

01:34 So that heart is working harder to compensate for the fact that that blood pressure is getting a little bit lower.

01:41 Other things that you might notice might include decreased capillary refill, and then you might notice that those hands and feet start getting a little bit cooler.

01:51 So that limb temperature's going to go down.

01:54 And you'll really be able to feel a difference in the temperature between the hands and feet and say, if you were to put your hand on the baby's chest.

02:03 You might also notice some decreased urine output.

02:07 As we get to the point where we're dehydrated, we don't urinate as much.

02:12 And then if you remember from previous presentations, also, we are really looking at that urine becoming darker, meaning it's more concentrated and there's just not enough body water for the patient to be able to urinate out.

02:27 Now another thing that happens when a patient is dehydrated is that inferior vena cava really starts collapsing a little bit.

02:35 And that is because there's not enough fluid rolling around through those blood vessels.

02:40 Now, you're not going to be able to notice that on your assessment but in critical care areas in ICUs, they can use an ultrasound monitor to really be able to see the fluid status of the patient.

02:55 So the next important consideration you are going to have is selecting the fluid type and the dose.

03:01 Your provider is likely going to order a fluid type and dose, but you need to be aware of the considerations so that you can make sure that this makes sense for your patients.

03:13 Most fluid bolus says should be with isotonic fluids.

03:17 Isotonic fluids include normal saline and lactated ringers and these are the most common fluids that you're going to be using to give a fluid bolus.

03:27 There are some indications that are not related to fluid balance but instead very specific and urgent emergent situations.

03:35 In those cases, you might be asked to give something other than normal saline and lactated ringers.

03:41 So some exceptions to isotonic fluid would be if you're using D5 Water to correct high sodium, you might be asked to give this in addition to maintenance fluids or as a separate dose itself.

03:56 You might be asked to give 3% normal saline and or Mannitol in increased ICP emergencies and that needs to be given fairly rapidly so it will feel like you're giving a bolus.

04:11 You might be asked to give dextrose to correct low glucose and sometimes that can be added to maintenance IV fluids or it can be given as a separate dose.

04:20 And occasionally, you'll be giving blood products and albumin.

04:24 If a patient has a low hemoglobin or hematocrit and they still have a very low volume and are very dehydrated.

04:33 Then occasionally, we will be giving blood products to get that fluid volume up.

04:40 The nurse should always question and or avoid any order for anything other than isotonic fluids.

04:47 But if there is a particular consideration that makes sense for your patient, then you can go ahead with the order.

04:56 So just know to question any order for hypertonic or hypotonic fluids.

05:03 So you might hear the terms Crystalloids and Colloids.

05:06 And what does that mean when you're talking about fluids? Crystalloids include normal saline, Lactated Ringers, and D5W.

05:14 So, those fluids have a tendency to be clear.

05:17 When you're talking about colloids, you're going to hear blood products and albumin.

05:22 So, those products are going to be thicker, and they're going to have some color to them.

05:28 And that's one of the ways that you can tell them apart.

05:31 So you're also going to want to know the typical fluid bolus doses.

05:36 And these might vary depend on your patient.

05:39 But you can assume that if you have a patient that is dehydrated, you're gonna give somewhere between 10 and 20 milliliters per kilogram.

05:49 So remember, in pediatrics, everything is done by weight.

05:53 So you're going to figure out the weight of your patient and 10 to 20 milliliters per kilogram of weight.

06:00 Now, the exception to that is if your patient has heart disease, so if they have heart failure, or they're in cardiogenic shock, you're going to give a little bit less fluids.

06:10 So the typical dose is going to be five milliliters per kilo.

06:16 The next important consideration to think about is really assessing your patient before you give the bolus.

06:23 So this is really important, you need to know what your patient looks like before you start giving that bolus.

06:30 You also need to know if your patient has a cardiac disease.

06:34 Now there are going to be some cases where you're not going to know if that baby has a problem with their heart.

06:41 And that is another reason why it is so important to assess your patient before you give the bolus so that if something isn't going right.

06:49 You're going to be able to pick up on that.

06:51 You also need to assess the respiratory rate and effort before you start giving the bolus.

06:57 You're going to want to feel pulses and check that capillary refill.

07:01 You're also going to want to auscultate those lung sounds.

07:04 Make sure that you don't hear anything that you shouldn't be hearing.

07:08 You want to think about the urine output.

07:10 Has that child had any urine output recently? And you're also going to check the blood pressure.

07:16 All of this should be done immediately before the bolus.

07:21 This way you're going to know whether that fluid bolus is successful or whether you might actually be causing harm by giving fluid to that patient.

07:32 There are a couple of signs of fluid boluses being harmful and you need to be very aware and this is, again, why assessment is so important.

07:41 So if your patient starts to have increased course and crackly breath sounds while you're giving that fluid bolus, if their work of breathing increases, or if their hypotension if their blood pressure gets worse as you're giving the bolus, that is a sign of that bolus being harmful.

08:02 So what are you going to do, if that bolus is not working in the way that you expect? You're going to slow down or more likely you're going to stop that fluid bolus.

08:16 So the next thing that you're going to think about when you're giving a fluid bolus is determining how fast you're gonna give this bolus.

08:24 So a standard rate of time for giving a fluid bolus is about 30 minutes.

08:30 If you have low urine output, but stable blood pressure, you know there's some dehydration you don't you need to give some extra fluid and a bolus has been ordered.

08:39 Usually 30 minutes is a good amount of time to give that bolus.

08:44 Now if this bolus is emergent, you can give that bolus in 10 minutes or less.

08:49 So it doesn't have to be given over 30 minutes.

08:52 So if you have a patient that has low blood pressure, or they are hemodynamically unstable, you're going to want to speed that fluid up.

09:00 So 10 minutes or less.

09:03 And how are you going to do that? So there are a couple of different ways to give a fluid bolus.

09:12 If you have the luxury of giving this bolus over 30 minutes or so you can put it on a pump and you can set your time.

09:20 If you don't have that luxury and you need to give it a little bit faster, you may use something like a pressure bag.

09:26 And in some instances, you may actually use a syringe where you're pulling fluid up into the syringe and there you're using that syringe plunger to push that fluid into the patient.

09:36 So that is why sometimes you'll hear this fluid bolus referred to as a push.