Tuesday, June 28, 2011

Management Health Solutions Launches Inventory Tracking Solution For Nation's Operating Rooms, Cath Labs


Management Health Solutions, Inc. (MHS), a leading provider of supply chain management solutions to hospitals and healthcare providers across the United States, announced the launch of Clinical Solutions (CS) – a new clinical inventory management module that focuses specifically on specialized surgery, cardiac catheterization and interventional radiology departments. 
Using the latest in clinical inventory technology, CS allows clinicians to manage supplies, devices and equipment right in the operating room or at the point of service.  Whether the supplies are on consignment or sold directly by the manufacturer or distributor, CS identifies, dates and captures current products, tracking how, when and by whom the product was used.  When needed, CS automatically replenishes stock to complete the supply chain cycle. 
“More than anything today, clinicians need all the time they can get to take care of patients and focus on healthcare,” said William Zierolf, president and CEO of Management Health Solutions, Inc.   “O.R.s are notorious for poorly tracking clinical supplies in a cost-effective way.  This technology frees nurses in the O.R., as well as in cath labs and radiology departments, from thinking about supplies so they can give all of their attention to delivering high quality care.  To the hospital itself, the technology means cost savings in the millions.” 
CS can easily integrate into a hospital’s existing O.R. scheduling, materials management or patient billing systems, or can be used on a standalone basis.  The solution leverages handheld devices developed for the hospital setting by AtPar, Inc., a leading developer of mobile supply chain software that is a new subsidiary of MHS.
AtPar’s supply chain solutions have been at work at BJC Healthcare, a 13-hospital IDN that has some 180,000 supply bin locations, and Marion Reynolds, BJC’s director of supply chain logistics, says the AtPar Receiving and Delivery modules implementation went extremely smooth. We had an overall system implementation schedule that was on-time, on-track and on-budget.” He says, “Most ERP companies offer a supply chain technology within their system but AtPar offers a modular approach that allows the IDN or facility to select the functionality and requirements that best meets their strategic direction.”
Reynolds says that “BJC will be migrating to an ERP solution over the next two years but will maintain the AtPar automation we have installed and will install. This year we will implement several more modules of AtPar solutions to improve our entire Supply Replenishment Process.”
To learn more about CS and MHS’s suite of complementary supply chain management solutions, visit www.mhsinc.com.

ABOUT ATPAR INC.
A subsidiary of Management Health Solutions, Inc. (MHS), AtPar Inc. is a supply chain execution software company offering a suite of well-integrated, feature-rich supply chain execution applications on handhelds that deliver business benefits in a short duration while maintaining a low cost of purchase and maintenance. Through the company’s knowledge and experience in deriving significant value from enterprise supply chain management systems and ERPs, AtPar Inc. has brought to market the @Par suite of products which specifically address the operational issues in supply chain management in hospitals. By combining significant domain knowledge, industry-standard technology and insight into the latest mobile technologies, we effectively deliver applications that integrate seamlessly with many of the industry’s materials management and supply chain management applications. For more information, visit www.atparinc.com.

Sunday, June 26, 2011

Get Over the Wall as a First-Year Nurse


Surviving your first year as a nurse will likely be one of the biggest challenges you will face in your career. Almost universally, first-year nurses have days, weeks or months when they feel overwhelmed, inadequate, disillusioned, stressed out or all of the above. If you’re thinking, “Was I really cut out for this job?” these tips can help you get through your first year as a nurse with your sanity, confidence and love of the profession intact.
Accept Your Limitations (and Keep Your Ego in Check)
Nursing school can often leave new nurses with unrealistic expectations. “A lot of nurses are Type A, brainy people who were used to getting good grades in nursing school, Nursing school is so hard that when you graduate, you think you know what you’re doing.” However, you won’t know everything all the time, but that doesn’t make you a bad nurse.

Don’t Try to Do It All
Likewise, new nurses must come to terms with the fact that they may not be able to accomplish everything on their to-do lists everyday. “You have to learn to accept that nursing is a 24/7 job, and you’re only there for 12 hours at a time, There’s always going to be something that you can’t be there for or that you can’t get done. You have to rely on a lot of other people.”
Ask for Help
Good nurses – whether newcomers or seasoned veterans – know when to call in reinforcements. That means asking doctors and more experienced nurses lots of questions. “Never be scared to ask questions, and don’t care if you are getting on someone’s nerves”.

Thursday, June 23, 2011

Consider Possibilities For Your First Job


So what can you do to make your transition from nursing student to working nurse easier and your first years on the job more satisfying? Here are some issues to ask about and consider before and after taking the job.

Ask About First-Year Nurse Turnover Rates

High turnovers indicate how the employer treats first-year nurses. Turnovers higher than 20 percent are generally considered high in the industry.

Find Out About Orientation and Preceptor Programs

A preceptor is a teacher and coach who helps nurses become oriented and familiar with a facility’s routines, procedures and people. New nurses are more likely to stay if they have an experienced and helpful preceptor. That’s why you should ask, “Will a preceptor be available on my shift after the orientation to answer questions and help with clinical decision making?”

Inquire About Support

Query the nurse manager about the level of clinical, social and emotional support available for new nurses. This support includes having experienced nurses on hand to help debrief a new nurse once he experiences a tragedy at work, such as a death. That debriefing must happen the day the event occurs, not a week later.

Observe the Unit

Simply touring the unit won’t give you a good idea of how people work together. Because it takes a while for people to let their guard down when someone is watching, make sure you observe for a few hours so you get a clearer picture of the unit’s interpersonal dynamics.

Consider Working on a Specialty Unit First

It’s actually easier for many new nurses to start on a specialty unit, such as labor and delivery or a highly staffed pediatrics unit, because the patients on those units are more homogeneous than those on a medical/surgical unit.
“If you take a position on a general medical/surgical unit, the range of patients is quite broad”. “If you work on intensive-care or coronary-care units, you will have more of a controlled patient population.”

Wednesday, June 22, 2011

Learn About Being a Nurse


Considering Nursing?

Nursing is the largest health care profession in the US, with over 2.9 million RNs nationwide. Because nurses are involved in every type of health care need from basic health to acute care, every nurse has followed a specific path of education to become an RN and develop an expertise.
Not sure where you fit? This guide was designed to educate you about our profession and help you identify the path to becoming a nurse that calls to you!
Nursing In America
  • 2.4 million Registered Nurses
  • 92% Percentage of RNs That are Women
  • 624,000 Projected growth in RNs (2002 – 2012)

What do Nurses do?

Although work settings and clinical populations may differ, all nurses are trained to perform the following duties:
Treat patients and alleviate their suffering 
Educate patients and families about care and wellness
Provide emotional support to patients’ family members
Record patients’ medical histories and monitor symptoms
Help perform diagnostic tests and medical procedures
Operate medical machinery
Administer treatments and medication

Where do Nurses Work?

Hospitals 56% 
Community Health Clinics 14.9%
Ambulatory Care 11.5%
Nursing Homes 6.3%
Nursing Education 2.6%

What Advanced Nursing Careers Are There?

An Advanced Practice Registered Nurse (APRN) is a global term used for the following specialization areas. All APRNs have a masters degree and met clinical practice requirements for their specialization.
Nurse Practitioner (NP) Nurse practitioners are able to deliver a wide range of primary care, preventive health, and women’s health care services, prescribe medication, and diagnose and treat common minor illnesses and injuries.
Certified Nurse-Midwife (CNM) Nurse-Midwives provide well-woman gynecological and low-risk obstetrical care. 
Clinical Nurse Specialist (CNS) Include specialization in treating various physical and mental health problems, and also work in consultation, research, education, and administration.
Certified Registered Nurse Anesthetists (CRNA) Administer more than 65% of anesthetics given to patients annually.

Explore Nursinglink.

Meet RNs and ask questions about their work, interests, likes and dislikes. This may teach you the most!

Monday, June 20, 2011

Management Health Solutions, Inc. Plans Expansion Following Acquisition, Secured Equity Investment


 Management Health Solutions, Inc. (MHS), a leading provider of supply chain management solutions to hospitals and healthcare providers across the United States, plans to expand the organization following two strategic moves recently completed, company officials announced.

MHS announced today the completion of a $7.0 million Series B equity investment led by Enhanced Equity Fund, L.P (EEF), a lower-middle market private equity fund focused on growth capital investing within certain sectors of the healthcare industry. The investment will be used to fund continued growth and expansion of the company’s suite of offerings.

Specifically, the secured funding allowed for the recent acquisition of AtPar, Inc., a leading developer of mobile supply chain software. The acquisition advances MHS’s clinical inventory management solution by complementing MHS’s proprietary inventory supply process, Optimal Inventory Control (OPTICSM), with mobile handheld inventory tracking technology.

“MHS has experienced revenue growth rates over 50 percent in the last several years that are even further fueled by both the right market conditions and EEF’s ongoing financial commitment,” said William Zierolf, president and CEO of Management Health Solutions, Inc.
“At a time of significant change in the healthcare industry, these milestones allow us to better serve our more than 500 clients throughout the nation. With our recent acquisition of AtPar and secured funding, MHS has an increased opportunity to play a key role in shaping the future of clinical supply chain management in the healthcare industry.”
Headquartered in Fairfield, Conn. since 2007, MHS plans to expand their local office and hire up to ten new employees over the next year, which will be an addition to their 150 employees worldwide. MHS also plans to develop key new products and services and has already begun rapidly expanding its current service offerings.
“As MHS grows, it is vital to our hospital partners that we continue investing in new cost-saving solutions through clinical materials management. We understand the importance of expanding our resources in order to successfully develop and integrate innovative products and services,” said Daniel Lubin, member of MHS’s board of directors and managing partner of Radius Ventures LLC, MHS’s existing institutional investor.
For additional information on MHS and their products and services, please visit www.mhsinc.com.

ABOUT ENHANCED EQUITY FUND, L.P.
Enhanced Equity Fund, L.P. (Enhanced Equity), with over $500 million of assets under management, is focused on providing equity capital to lower-middle market growth companies (typically less than $100 million in revenues) in the healthcare industry.  As part of their investment philosophy, Enhanced Equity partners with successful entrepreneurs and management teams to build value through both internal growth strategies and acquisitions in order to transform their businesses into market leaders. To learn more about Enhanced Equity, visit www.enhancedequity.com.

ABOUT RADIUS VENTURES, LLC.
Radius Ventures, LLC (Radius) is a venture capital firm focused on leading-edge health and life sciences companies. Investments are sought across the industry’s key sectors including biotechnology and pharmaceuticals, medical devices, services, and healthcare/life sciences information technology. Radius currently manages three funds with total committed capital of approximately $200 million. Generally, Radius invests up to $8 million in aggregate, as a lead or syndicate investor. For more information, visit www.radiusventures.com.


Thursday, June 16, 2011

Management Health Solutions, Inc. (MHS) Secures $7.0 Million Series B Equity Investment


 Management Health Solutions, Inc. (MHS), a leading provider of supply chain management solutions to hospitals and healthcare providers across the United States, announced today the completion of a $7.0 million Series B equity investment led by Enhanced Equity Fund, L.P. (Enhanced Equity). Radius Ventures, LLC (Radius), the company’s existing institutional investor, also participated in the financing round.
The Series B investment was used to fund the company’s recent acquisition of AtPar, Inc., a provider of mobile technology solutions that increase efficiencies in managing clinical supply inventories primarily within the hospital setting. The investment will also fund continued growth and expansion of the company’s suite of hospital supply chain management offerings.
“We are eager to begin our relationship with Enhanced Equity because their expertise in the healthcare services and healthcare information technology sectors, coupled with their vast network of industry relationships, will make them a valuable partner as MHS grows,” said William Zierolf, president and CEO of Management Health Solutions, Inc.
“Enhanced Equity’s current and ongoing commitment to MHS strengthens our financial foundation and is critical to our ability to continue to deliver innovative supply chain management solutions that assist our hospital clients in controlling the rising cost of healthcare while improving patient safety.”
Enhanced Equity is a lower-middle market private equity fund focused on growth capital investing within certain sectors of the healthcare industry.  It is currently investing out of its second fund and manages funds in excess of $500 million. 
“We are keenly interested in investing in healthcare enterprises that reduce system costs in delivering healthcare nationwide,” said Brett Fliegler, partner at Enhanced Equity.
“MHS’s solutions are squarely centered on increasing efficiencies within the hospital setting which, in turn, lower costs and improve capital utilization for the hospital. We see great potential for MHS to play a key role in shaping the future of clinical supply chain management in the healthcare industry, particularly with MHS’s recent acquisition of AtPar which further transforms MHS’s capabilities to develop and advance its OPTIC solution.”
The addition of AtPar’s mobile technology complements MHS’s Optimal Inventory Control (OPTICSM) model – the company’s proprietary process of clinical inventory optimization – by adding handheld inventory tracking technology to its suite of supply chain management solutions.
Enhanced Equity joins MHS’s existing institutional investor, Radius Ventures, a venture capital firm focused on leading-edge health and life sciences companies.
“MHS’s partnership with Enhanced Equity brings MHS a terrific capital partner with dedicated healthcare industry expertise,” said Daniel Lubin, managing partner of Radius and member of MHS’s board of directors. 
“Having worked with MHS for two years, we have never been more excited about the importance of the company's value proposition to our hospital partners. MHS is well-positioned to enhance its existing offering and develop key new products and services, all fueled by the ongoing commitment by Enhanced Equity and Radius.” 
For additional information on MHS and their products and services, please visit www.mhsinc.com.

ABOUT ENHANCED EQUITY FUND, L.P.
Enhanced Equity Fund, L.P. (Enhanced Equity), with over $500 million of assets under management, is focused on providing equity capital to lower-middle market growth companies (typically less than $100 million in revenues) in the healthcare industry.  As part of their investment philosophy, Enhanced Equity partners with successful entrepreneurs and management teams to build value through both internal growth strategies and acquisitions in order to transform their businesses into market leaders. To learn more about Enhanced Equity, visit www.enhancedequity.com.
ABOUT RADIUS VENTURES, LLC.
Radius Ventures, LLC (Radius) is a venture capital firm focused on leading-edge health and life sciences companies. Investments are sought across the industry’s key sectors including biotechnology and pharmaceuticals, medical devices, services, and healthcare/life sciences information technology. Radius currently manages three funds with total committed capital of approximately $200 million. Generally, Radius invests up to $8 million in aggregate, as a lead or syndicate investor. For more information, visit www.radiusventures.com.

Wednesday, June 15, 2011

What Every Nurse Should Expect from their Chosen Nursing Agency


As a clinical nurse working through an agency, the arrangement is often referred to as ‘casual’ work or ‘casual’ shifts. However, the relationship forged between the Nurse and the Agency isn’t ‘casual’ at all. This relationship is built on trust and respect, both expressed and implied.
As a Nursing Agency, the elements of trust revolve around a number of essential aspects:
Financial
  • Your chosen agency should provide you with the most competitive rate of pay it can secure. The probability of you gaining work should not be hindered by excessive agency fees.
  • The cost of processing a nursing payroll should be covered by the agency. This means no or minimal bank fees flowing on to you as nursing staff.
  • The frequency of the payment should be customized to meet your financial lifestyle. Decide what pay schedule is more convenient – do you wish to be paid weekly or fortnightly?
  • Your agency should inform you of your current rate of pay and other entitlements. You should have quick access to accurate information on this subject. There should also be effective procedures in place to assist you to deal with incorrect payments (or any queries you may have) in a timely manner.

Superannuation
  • Your entitlement is based upon an Australian Taxation Office calculation that states: ‘if the nurse earns a gross of over $450 per month then the Agency shall contribute 9% of the nurses gross wage into the nurse’s nominated fund.’
  • While it is true that the process time it takes some funds to allocate contributions into member’s accounts is lengthy, remember that all super funds begin accruing interest from the time the payment is received from the agency.
  • Responsible agencies pay super on a quarter by quarter basis, as scheduled by the ATO. There should be no catch here – Superannuation should be paid on time, every time.
  • Superannuation information should be validated by your pay slip and the statement generated by the nominated Superannuation fund.
  • Superannuation is not only a legal obligation; it is a matter of trust.
Working Conditions
  • There is good proof that correct clinical placement is the proven method for achieving good working conditions. You should be placed in a working environment that matches your skills, strengths and personal goals. Your Nursing Agency should take the time to listen to your aspirations and take into consideration any concerns or anxieties you may have in a workplace setting.
Provision for Ongoing Nursing Education
  • Resources should be made available to allow the all-important accrual of Continuous Professional Education Points towards your re-registration.
  • Continued up-skilling will provide you with correct clinical placement in a rapidly evolving clinical area with new technology.
  • Keeping up clinically with the technology push isn’t just a nurse’s responsibility; it’s a joint responsibility with the Nursing Agency.
Safety
  • A top priority for any corporation or agency – be it nursing or not – is making sure you are safe.
  • The intended result of the training should be a confident nurse being allocated the clinical area of their chosen competency, with the full support of his or her agency.

Tuesday, June 14, 2011

I.V. fluids: What nurses need to know

CAN YOU IMAGINE A LIFE without water? Of course not, because water is essential to sustain life. Likewise, body fluids are vital to maintain normal body functioning.

The body reacts to internal and environmental changes by adjusting vital functions to keep fluids and electrolytes in balance, maintaining homeostasis. This article will explore how fluid acts within the body and discuss when and why various I.V. fluids can be used to maintain homeostasis. Subsequent articles in this series will discuss specific electrolyte imbalances. Unless otherwise specified, information applies to adults, not pediatric patients.

Water water everywhere

Solutions are comprised of fluid (the solvent) and particles (the solute) dissolved in the fluid. Water is the body's primary fluid and is essential for proper organ system functioning and survival. Although people can live several weeks without food, they can survive only a few days without water.

Water has many functions in the body; for example, it
* serves as the transport system for nutrients, gases, and wastes in and out of the cells.

* facilitates the elimination of wastes through the kidneys, gastrointestinal (GI) tract, skin, and lungs.

* regulates body temperature through evaporation from the skin.
Water is gained and lost from the body every day. For the body to maintain normal function, the intake and output of fluid should remain fairly equal. We obtain water through drinking fluids and the metabolism of nutrients obtained from eating foods.

Fluid intake is regulated by the thirst mechanism in the brain. This mechanism is stimulated when blood fluid volume decreases. Increased osmolality stimulates the thirst center, triggering the impulse to increase fluid intake.

Water is lost from the body through the kidneys, GI tract, lungs, and skin. Losses from the kidneys and GI tract are known as sensible lossesbecause they can be measured. Insensible losses describe water loss that can't be measured, including losses through the skin from evaporation and through the lungs from respiration.

Two main fluid compartments

Fluids within the body are contained in two basic compartments, intracellular and extracellular. Cell membranes and capillary walls separate the two fluid compartments. See Two basic fluid compartments.

The intracellular fluid compartment, which consists of fluid contained within all of our body cells, is the larger of the two compartments. The extracellular fluid compartment contains all the fluids outside the cells and is further divided into two major subcomponents: intravascular fluidcontained in blood vessels and interstitial fluid found in the tissue spaces. The intracellular, intravascular, and interstitial spaces are the major fluid compartments in the body.

A third category of the extracellular fluid compartment is the transcellular compartment, which includes cerebrospinal fluid and fluid contained in body spaces such as the pleural cavity and joint spaces. Because transcellular fluids don't normally contribute significantly to fluid balance, they're beyond the scope of this article.

How much of you is water?

The amount of water in the body varies depending on age, gender, and body build. In nonobese adults, intracellular fluid constitutes approximately 40% of body weight, and extracellular fluid, 20%. (See How body fluid is distributed.)

Lean body muscle mass is rich in water, while adipose tissue has a lower percentage of water content. Because of this, someone who's overweight or obese has a lower percentage of water overall compared with someone who's lean and muscular. Similarly, women typically have a lower percentage of total body water than men due to a higher percentage of body fat. Older adults tend to have a lower concentration of water overall, due to an age-related decrease in muscle mass. Conversely, children tend to have a higher percentage of water weight-as much as 80% in a full-term neonate.

Fluids don't remain static within body compartments; instead, they move continuously among them to maintain homeostasis. Cell membranes are semipermeable, meaning they allow fluid and some solutes (particles dissolved in a solution) to pass through.

Fluids and electrolytes move between compartments via passive and active transport. Passive transport occurs when no energy is required to cause a shift in fluid and electrolytes. Diffusion, osmosis, and filtration are examples of passive transport mechanisms that cause body fluid and electrolyte movement.

Osmolality and osmolarity are two similar terms that are often confused. Osmolality, which is usually used to describe fluids inside the body, refers to the solute concentration in fluid by weight: the number of milliosmols (mOsm) in a kilogram (kg) of solution. Osmolarity refers to the solute concentration in fluid by number of mOsm per liter (L) of solution. Because 1 L of water weighs 1 kg, the normal ranges are the same and the terms are often used interchangeably.

Changes in the level of solute concentration influence the movement of water between the fluid compartments. The normal osmolality for plasma and other body fluids varies from 270 to 300 mOsm/L. Optimal body function occurs when the osmolality of fluids in all the body compartments is close to 300 mOsm/L. When body fluids are fairly equivalent in this particle concentration, they're said to be isotonic.

Fluids with osmolalities less than 270 mOsm/L are hypotonic in comparison with isotonic fluids, and fluids with osmolalities greater than 300 mOsm/L are hypertonic. Tonicity of I.V. fluids will be discussed in detail later in this article.

Through the use of mechanisms such as thirst, the renin-angiotensin-aldosterone system, antidiuretic hormone, and atrial natriuretic peptide, the body works to maintain appropriate fluid and electrolyte levels and to prevent imbalances within the body. When an imbalance occurs, you must be able to identify the cause of the problem and monitor the patient during treatment.

Crystalloids vs. colloids

One of the methods for treating fluid and electrolyte alterations is the infusion of I.V. solutions, which have distinctive differences in composition that affect how the body reacts to and utilizes them. When administering I.V. therapy, you need to understand the nature of the solution being initiated and how it will affect your patient's condition.

I.V. solutions for fluid replacement may be placed in two general categories: colloids and crystalloids. Colloids contain large molecules that don't pass through semipermeable membranes. When infused, they remain in the intravascular compartment and expand intravascular volume by drawing fluid from extravascular spaces via their higher oncotic pressure. We'll discuss colloids in detail later.

Crystalloids are solutes capable of crystallization that are easily mixed and dissolved in a solution. The solutes may be electrolytes or nonelectrolytes, such as dextrose.

Crystalloid solutions contain small molecules that flow easily across semipermeable membranes, allowing for transfer from the bloodstream into the cells and body tissues. This may increase fluid volume in both the interstitial and intravascular spaces.

Crystalloid solutions are distinguished by their relative tonicity (before infusion) in relation to plasma. Tonicity refers to the concentration of dissolved molecules held within the solution. The following sections discuss isotonic, hypotonic, and hypertonic crystalloid solutions in detail.

ISOTONIC FLUIDS

A solution is isotonic when the concentration of dissolved particles is similar to that of plasma. Isotonic solutions have an osmolality of 250 to 375 mOsm/L. With osmotic pressure constant both inside and outside the cells, the fluid in each compartment remains within its compartment (no shift occurs) and cells neither shrink nor swell. Because isotonic solutions have the same concentration of solutes as plasma, infused isotonic solution doesn't move into cells. Rather, it remains within the extracellular fluid compartment and is distributed between the intravascular and interstitial spaces, thus increasing intravascular volume. Types of isotonic solutions include 0.9% sodium chloride (0.9% NaCl), lactated Ringer's solution, 5% dextrose in water (D5W), and Ringer's solution.

A solution of 0.9% sodium chloride is simply salt water, and contains only water, sodium (154 mEq/L), and chloride (154 mEq/L). It's often called "normal saline solution" because the percentage of sodium chloride dissolved in the solution is similar to the usual concentration of sodium and chloride in the intravascular space.

Because water goes where sodium goes, 0.9% sodium chloride increases fluid volume in extracellular spaces. It's administered to treat low extracellular fluid, as in fluid volume deficit from hemorrhage, severe vomiting or diarrhea, and heavy drainage from GI suction, fistulas, or wounds. Conditions commonly treated with 0.9% sodium chloride include shock, mild hyponatremia, metabolic acidosis (such as diabetic ketoacidosis), and hypercalcemia; patients requiring a fluid challenge may also benefit from 0.9% sodium chloride solution. It's the fluid of choice for resuscitation efforts. In addition, it's the only fluid used with administration of blood products.

Remember that because 0.9% sodium chloride replaces extracellular fluid, it should be used cautiously in certain patients, such as those with cardiac or renal disease, because of the potential for fluid volume overload.
Lactated Ringer's (LR), also known as Ringer's lactate or Hartmann solution, is the most physiologically adaptable fluid because its electrolyte content is most closely related to the composition of the body's blood serum and plasma. Because of this, LR is another choice for first-line fluid resuscitation for certain patients, such as those with burn injuries. It contains 130 mEq/L of sodium, 4 mEq/L of potassium, 3 mEq/L of calcium, and 109 mEq/L of chloride. LR doesn't provide calories or magnesium, and has limited potassium replacement.

LR is used to replace GI tract fluid losses, fistula drainage, and fluid losses due to burns and trauma. It's also given to patients experiencing acute blood loss or hypovolemia due to third-space fluid shifts. Both 0.9% sodium chloride and LR may be used in many clinical situations, but patients requiring electrolyte replacement (such as surgical or burn patients) will benefit more from an infusion of LR.

LR is metabolized in the liver, which converts the lactate to bicarbonate. As an alkalinizing solution, LR is often administered to patients who have metabolic acidosis. Don't give LR to patients who can't metabolize lactate for some reason, such as those with liver disease or those experiencing lactic acidosis.

Because a normal liver will convert it to bicarbonate, LR shouldn't be given to a patient whose pH is greater than 7.5. Because it does contain some potassium, use caution in patients with renal failure.
Ringer's solution, like LR, contains sodium, potassium, calcium, and chloride in similar concentrations (147 mEq/L of sodium, 4 mEq/L of potassium, 4 mEq/L of calcium, and 156 mEq/L of chloride). But it doesn't contain lactate. Ringer's solution is used in a similar fashion as LR, but doesn't have the contraindications related to lactate. However, because it's not an alkalizing agent, it may not be indicated for patients with metabolic acidosis.

D5W is unique in that it may be categorized as both an isotonic and a hypotonic solution. The amount of dextrose in this solution makes its initial tonicity similar to that of intravascular fluid, making it an isotonic solution. But dextrose (in this concentration) is rapidly metabolized by the body, leaving no osmotically active particles in the plasma.

D5W provides free water: free, unbound water molecules small enough to pass through membrane pores to the intracellular and extracellular spaces. This smaller size allows the molecules to pass more freely between compartments, thus expanding both compartments simultaneously.The free water initially dilutes the osmolality of the extracellular fluid; once the cell has used the dextrose, the remaining saline and electrolytes are dispersed as an isotonic electrolyte solution, providing additional hydration for the extracellular fluid compartment. Dextrose solutions also provide free water for the kidneys, aiding renal excretion of solutes. Because it provides free water following metabolism, D5W is also considered a hypotonic solution.

D5W is basically a sugar water solution that provides 170 calories per liter, but it doesn't replace electrolytes. However, it's appropriate to treat hypernatremia because it dilutes the extra sodium in extracellular fluid.

D5W shouldn't be used in isolation to treat fluid volume deficit because it dilutes plasma electrolyte concentrations. It's also contraindicated in these clinical circumstances:

* for resuscitation, because the solution won't remain in the intravascular space.

* in the early postoperative period, because the body's reaction to the surgical stress may cause an increase in antidiuretic hormone secretion.

* in patients with known or suspected increased intracranial pressure (ICP) due to its hypotonic properties following metabolism.
Although it supplies some calories, D5W doesn't provide enough nutrition for prolonged use.

Nursing considerations for isotonic solutions

Be aware that patients being treated for hypovolemia can quickly develop hypervolemia (fluid volume overload) following rapid or overinfusion of isotonic fluids. Document baseline vital signs, edema status, lung sounds, and heart sounds before beginning the infusion, and continue monitoring during and after the infusion.

Frequently assess the patient's response to I.V. therapy, monitoring for signs and symptoms of hypervolemia, such as hypertension, bounding pulse, pulmonary crackles, dyspnea/shortness of breath, peripheral edema, jugular venous distention (JVD), and extra heart sounds, such as S3. Monitor intake and output, hematocrit, and hemoglobin. Elevate the head of bed at 35 to 45 degrees, unless contraindicated. If edema is present, elevate the patient's legs. Note if the edema is pitting or nonpitting and grade pitting edema. For an example, see Checking for pitting edema.

Also monitor for signs and symptoms of continued hypovolemia, including urine output of less than 0.5 mL/kg/hour, poor skin turgor, tachycardia, weak, thready pulse, and hypotension.

Educate patients and their families about signs and symptoms of volume overload and dehydration, and instruct patients to notify their nurse if they have trouble breathing or notice any swelling. Instruct patients and families to keep the head of the bed elevated (unless contraindicated).

HYPOTONIC FLUIDS

Compared with intracellular fluid (as well as compared with isotonic solutions), hypotonic solutions have a lower concentration, or tonicity, of solutes (electrolytes). Hypotonic I.V. solutions have an osmolality less than 250 mOsm/L.

Infusing a hypotonic solution into the vascular system causes an unequal solute concentration among the fluid compartments. The infusion of hypotonic crystalloid solutions lowers the serum osmolality within the vascular space, causing fluid to shift from the intravascular space to both the intracellular and interstitial spaces. These solutions will hydrate cells, although their use may deplete fluid within the circulatory system.

Types of hypotonic fluids include 0.45% sodium chloride (0.45% NaCl), 0.33% sodium chloride, 0.2% sodium chloride, and 2.5% dextrose in water. Hypotonic solutions assist with maintaining daily body fluid requirements, but don't contain any electrolytes (except for sodium and chloride) or calories (except for D5W, which is also considered a hypotonic solution after metabolism). Administering hypotonic saline solutions also helps the kidneys excrete excess fluids and electrolytes.

All these solutions provide free water, sodium, and chloride, and replace natural fluid losses. In addition, the solution containing dextrose offers a low level of caloric intake.

Nursing considerations for hypotonic solutions

Hypotonic fluids are used to treat patients with conditions causing intracellular dehydration, such as diabetic ketoacidosis, and hyperosmolar hyperglycemic state, when fluid needs to be shifted into the cell. Be aware of how the fluid shift will affect various body systems. The lower concentration of solute within the vascular bed will shift the fluid into the cells and also into the interstitial spaces.

Use caution when infusing hypotonic solutions; the decrease in vascular bed volume can worsen existing hypovolemia and hypotension and cause cardiovascular collapse.

Monitor patients for signs and symptoms of fluid volume deficit as fluid is "pulled back" into the cells and out of the vascular bed. In older adult patients, confusion may also be an indicator of a fluid volume deficit. Instruct patients to inform a nurse if they feel dizzy or just "don't feel right."
Never give hypotonic solutions to patients who are at risk for increased ICP because of a potential fluid shift to the brain tissue, which can cause or exacerbate cerebral edema. In addition, don't use hypotonic solutions in patients with liver disease, trauma, or burns due to the potential for depletion of intravascular fluid volume.

HYPERTONIC SOLUTIONS

Compared with intracellular fluid (as well as with isotonic solutions), hypertonic solutions have a higher tonicity or solute concentration, causing an unequal pressure gradient between the inside and outside of the cells. Hypertonic fluids have an osmolarity of 375 mOsm/L or higher. The osmotic pressure gradient draws water out of the intracellular space, increasing extracellular fluid volume. Because of this property, hypertonic solutions are used as volume expanders. Hypertonic solutions may be prescribed for patients with severe hyponatremia. Patients with cerebral edema may also benefit from an infusion of hypertonic sodium chloride.

Hypertonic sodium chloride solutions contain a higher concentration of sodium and chloride than that normally contained in plasma. Examples include 3% sodium chloride (3% NaCl), with 513 mEq/L of sodium and chloride, and 5% sodium chloride (5% NaCl), with 855 mEq/L of sodium and chloride. As the infusion of these hypertonic solutions raise the sodium level in the bloodstream, osmosis comes into play, removing fluid from the intracellular space, and shifting it into the intravascular and interstitial spaces. These solutions are highly hypertonic and should be used only in critical situations to treat hyponatremia. Give them slowly and cautiously to avoid intravascular fluid volume overload and pulmonary edema.

When dextrose is added to isotonic or hypotonic solutions, the net result can be a slightly hypertonic solution due to the higher solute concentration. Thus, adding D5W to sodium chloride solutions (such as 5% dextrose and 0.45% sodium chloride, and 5% dextrose and 0.9% sodium chloride) or to lactated Ringer's solutions such as D5LR will provide the same electrolytes already discussed for each of those solutions, with the addition of calories. Plain glucose solutions with a concentration higher than 5%, such as 10% dextrose in water (D10W), are also considered hypertonic. D10W provides free water and calories (340 per liter), but not electrolytes.

Twenty percent dextrose in water (D20W) is an osmotic diuretic, meaning the fluid shift it causes between various compartments promotes diuresis.

Fifty percent dextrose in water (D50W) is a highly concentrated sugar solution. It's administered rapidly via I.V. bolus to treat patients with severe hypoglycemia.

Nursing considerations for hypertonic solutions

Maintain vigilance when administering hypertonic saline solutions because of their potential for causing intravascular fluid volume overload and pulmonary edema. Hypertonic sodium chloride solutions should be administered only in high acuity areas with constant nursing surveillance for potential complications. Hypertonic sodium chloride shouldn't be given for an indefinite period of time. Prescriptions for their use should state the specific hypertonic fluid to be infused, the total volume to be infused and infusion rate, or the length of time to continue the infusion. As an additional precaution, many institutions store hypertonic sodium chloride solutions apart from regular floor stock I.V. fluids, so they must be ordered separately from the pharmacy.

Monitor serum electrolytes and assess for signs and symptoms of hypervolemia. Because hypertonic solutions can cause irritation, damage, and thrombosis of the blood vessel, some of these solutions shouldn't be administered peripherally. The Infusion Nurses Society states that "[p]arenteral nutrition solutions containing final concentrations exceeding 10% dextrose should be administered through a central vascular access device with the tip located in the central vasculature, preferably the subclavian/right atrium junction for adults."

Instruct patients to notify a nurse if they develop breathing difficulties or if they feel their heart is beating very fast.

Hypertonic solutions shouldn't be given to patients with cardiac or renal conditions who are dehydrated. These solutions affect renal filtration mechanisms and can cause hypervolemia. Patients with conditions causing cellular dehydration, such as diabetic ketoacidosis shouldn't be given hypertonic solutions, because it will exacerbate the condition.

Why colloid solutions stay put

Unlike crystalloids, colloids contain molecules too large to pass through semipermeable membranes, such as capillary walls. Because they remain in the intravascular compartment, they're also known as volume expanders or plasma expanders. Examples include albumin, dextrans, and hydroxyethylstarches.

Colloids expand intravascular volume by drawing fluid from the interstitial spaces into the intravascular compartment through their higher oncotic pressure. They have the same effect as hypertonic crystalloids of increasing intravascular volume, but require administration of less total volume compared with crystalloids. In addition, colloids have a longer duration of action than crystalloids because the molecules remain within the intravascular space longer. The effects of colloids can last for several days if capillary wall linings are intact and working properly. Colloids are indicated for patients exhibiting hypoproteinemia, and malnourished states, as well as for those who require plasma volume expansion but who can't tolerate large infusions of fluid. Patients undergoing orthopedic surgery or reconstructive procedures with an elevated potential for thrombus formation may also benefit from colloid solutions.

Five percent albumin (Human albumin solution) is one of the most commonly utilized colloid solutions. It contains plasma protein fractions obtained from human plasma and works to rapidly expand the plasma volume. It's used for volume expansion, moderate protein replacement, and achievement of hemodynamic stability in shock states. Albumin is also available in a 25% solution, which is much more hypertonic and can draw about four times its volume from the interstitial fluid into the vascular compartment within 15 minutes of administration.

Albumin is considered a blood transfusion product and requires all the same nursing precautions used when administering other blood products. It can be expensive and its availability is limited to the supply of human donors.

Albumin is, however, contraindicated in patients with the following conditions: severe anemia, heart failure, or a known sensitivity to albumin. In addition, angiotensin-converting enzyme inhibitors should be withheld for at least 24 hours before administering albumin because of the risk of atypical reactions, such as flushing and hypotension.

A study was conducted during 2001-2003 called the Saline versus Albumin Fluid Evaluation (SAFE) study. This study compared the use of albumin and saline for ICU patients requiring fluid resuscitation. Among 6997 patients studied, 3497 received 4% albumin solution and 3500 received 0.9% sodium chloride solution. The aim of the study was to determine if one fluid was better than the other for preventing death. After 28 days, researchers found similar outcomes in both groups. Because neither solution has proven clearly superior, healthcare providers use their judgment to decide which fluid to administer to critically ill patients in the ICU.

Besides albumin, several synthetic colloid preparations are available for patient use. Low-molecular weight dextran (LMWD) and high-molecularweight dextran(HMWD) are synthetic plasma expanders infused to draw water into the intravascular space.

* LMWD contains polysaccharide molecules that behave like colloids with an average molecular weight of 40,000 (dextran 40). It contains no electrolytes and is used for volume expansion and support. LMWD is used for early fluid replacement and to treat shock related to vascular volume loss, such as that produced by burns, hemorrhage, surgery, or trauma. It's used to prevent venous thromboembolism during surgical procedures, because its mechanism of action is to prevent the sludging of blood. LMWD is contraindicated in patients with thrombocytopenia, hypofibrinogenemia, and hypersensitivity to dextran.

* HMWD contains polysaccharide molecules with an average molecular weight of 70,000 (available as dextran 70) or 75,000 (available as dextran 75). It also contains no electrolytes. HMWD shouldn't be given to patients in hemorrhagic shock.

Dextran solutions are available in either saline or glucose solutions. Dextran interferes with lab blood crossmatching, so if a type and cross is anticipated, draw the patient's blood before administering dextran. Dextran may interfere with some other blood tests and may also cause anaphylactoid reactions.

Hydroxyethalstarches, such as hetastarch (6%) and hespan, are another form of hypertonic synthetic colloids used for volume expansion. They contain 154 mEq/L of sodium and chloride and are used for hemodynamic volume replacement following major surgery and to treat major burns. Synthetic colloid preparations are less expensive than albumin and their effects can last 24 to 36 hours.

Unlike other colloids, hetastarch doesn't interfere with blood typing or crossmatching. Hetastarch is contraindicated in patients with liver disease and severe cardiac and renal disorders. It may also cause a severe anaphylactoid reaction.

Nursing considerations for colloids

Because colloids pull fluids from the interstitial space to the vascular space, the patient is at risk for developing fluid volume overload. If the patient's fluid imbalance doesn't respond to either crystalloids or colloids, blood transfusions or other treatment may be necessary.

As for blood products, use an 18-gauge or larger needle to infuse colloids. Monitor the patient for signs and symptoms of hypervolemia, including increased BP, dyspnea, crackles in the lungs, JVD, edema, and bounding pulse. Closely monitor intake and output. Colloid solutions can interfere with platelet function and increase bleeding times, so monitor the patient's coagulation indexes. Elevate the head of bed unless contraindicated.

Anaphylactoid reactions are a rare but potentially lethal adverse reaction to colloids. Take a careful allergy history from patients receiving colloids (or any other drug or fluid), asking specifically if they've ever had a reaction to an I.V. infusion.

Use best practices for optimal outcomes

No matter what I.V. fluid you're administering, follow best practices to ensure optimal response to therapy and prevent complications. For example, assess and document baseline vital signs, heart and lung sounds, and fluid volume status.

As with any drug, make sure you're familiar with the type of fluid being administered, the rate and duration of the infusion, the fluid's effects on the body, and potential adverse reactions. Throughout therapy, monitor the patient's response to treatment, watching closely for any signs and symptoms of hypervolemia or hypovolemia. Monitor lab values to assess kidney function and fluid status. Regularly check the venous access site for signs of infiltration, inflammation, infection, or thrombosis.

Educate the patient and the family about the prescribed therapy, including potential complications and symptoms that require immediate attention.

Crucial balancing act

Maintaining fluid and electrolyte balance is essential for life. Future articles in this series will discuss how to assess for specific imbalances and intervene appropriately.