FLUIDS &

ELECTROLYTES
JENNIFER H. MESDE, RN, MAN
BODY FLUIDS
I. ADULTS


a.Women: 50-55% body weight is water

b.Men: 60-70% body weight is water
c.Elderly: 47% body weight is water


II. INFANTS
 75-80% body weight is water
DISTRIBUTION OF BODY
FLUIDS
 INTRACELLULAR : 80% of total body water
◦ Found within the cells of the body
◦
 EXTRACELLULAR: 20% of total body water
◦ Found outside the cells and accounts for about
1/3 of total body fluid
a.Interstitial - 75%
b.Intravascular (plasma) - 20%
c.Other: cerebrospinal fluid, intraocular fluid,
bone water, gastrointestinal secretions
COMPOSITION OF BODY
BLUIDS
 IONS
◦ Charge particles


 ELECTROLYTES
◦ Charge particles
◦ They are capable of conducting energy
◦
 Cations – positive charge ions


Anions – negative charge ions

◦
COMPOSITION OF BODY
FLUIDS
 ELECTROLYTES
◦ Extracellular
a.Sodium (Na+) 135-145 mEq/l
b.Calcium (Ca++ ) 8-10 mg/dl
c.Chloride (Cl-) 85-145 mEq/l
d.Bicarbonate (HCO3-) 22-29 mEq/l
◦ Intracellular
a.Potassium (K+) 3.5-5.5 mEq/l
b.Phosphate (PO4) 2.5-4.5 mg/dl
c.Magnesium (Mg+) 1.3 -2.0 mEq/l
ELECTROLYTE
COMPOSITION
Functions of Electrolytes
a.Promote neuromuscular excitability
b.Maintain fluid volume
c.Distribute water between fluid
compartments
d.Regulate acid-base balance
MOVEMENT OF FLUIDS &
ELECTROLYTES


 OSMOSIS
◦
◦ the movement of water across cell
membranes from the less
concentrated solution to the more
concentrated solution


osmosis
OSMOLALITY
 Concentration of solutes in body fluids
 Determined by the total solute concentration
within a fluid compartment
 Measured as part of solute per kilogram of
water


 OSMOTIC PRESSURE
◦ The power of the solution to draw water across a
semi-permeable membrane
◦
 COLLOID OSMOTIC PRESSURE OR ONCOTIC
PRESSURE
◦ Pulling water from the interstitial space into the
vascular compartment

11
diffusion
 Is the continual intermingling of molecules
in liquids, gases, or solids brought about
by random movement of the molecules
 the process by which molecules spread from
areas of high concentratiion, to areas of
low concentration. When the molecules are
even throughout a space - it is called
EQUILIBRIUM
 Concentration gradient - a difference
between concentrations in a space.

FILTRATION
 Process whereby fluid and solutes move
together across a membrane from one
compartment to another
 The movement is from an area of higher
pressure to one of lower pressure
ACTIVE TRANSPORT
 Substance move across cell membranes
from a less concentrated one
 The sodium-potassium pump
REGULATING BODY FLUIDS
AVERAGE DAILY FLUID INTAKE OF AN ADULT
SOURCE AMOUNT (ML)

Oral fluids 1,200 to 1,500

Water in foods 1,000
Water-as-by-products of food 200
metabolism

Total 2,400 to 2,700

Fluid intake
 Healthy adult ingests fluid as part of the
dietary intake.
 90% of intake is from the ingested food and
water
 10% of intake results from the products of
cellular metabolism
 Usual intake of adult is about 2, 500 ml per
day
 The other sources of fluid intake are: IVF,
TPN, Blood products, and colloids
THIRST MECHANISM
FLUID OUTPUT
 The average fluid losses amounts to 2, 500 ml per day,
counterbalancing the input.

 The routes of fluid output are the following:
 SENSIBLE LOSS- Urine, feces or GI losses, sweat
 INSENSIBLE LOSS- though the skin and lungs as water
vapor
 URINE- is an ultra-filtrate of blood. The normal output is
1400 to 1,500 ml/day or 30-50 ml per hour or 0.5-1 ml
per kilogram per hour. Urine is formed from the
filtration process in the nephron
 FECAL loss- usually amounts to about 200 ml in the stool
 Insensible loss- occurs in the skin and lungs, which are
not noticeable and cannot be accurately measured.
Water vapor goes out of the lungs and skin.

MAINTAINING
HOMEOSTASIS
 Kidneys
 Antidiuretic Hormones
 Renin-Angiotensin-Aldosterone System
 Atrial Natriuretic Factor (ANF)
KIDNEYS
KIDNEYS
 Maintenance of water and electrolyte
balance
 Regulation of volume and chemical
makeup of the blood
 Conversion of Vit D to active form
 Production of Renin

KIDNEYS
ADH
Renin-Angiotensin-
Aldosterone System
Renin-Angiotensin-Aldosterone
System (RAAS)
 Renin – from renin substrates produced by the
lungs
 Angiotensin
◦ Angiotensin 1- harmless enzyme
◦ Angiotensin 2 – converted A1; requires ACE for
conversion
 Aldosterone – promotes Na retention

26
REGULATING
ELECTROLYTES
SODIUM
 The most abundant cation in the ECF
 Normal range in the blood is 135-145
mEq/L
 A loss or gain of sodium is usually
accompanied by a loss or gain of water.
 Major contributor of the plasma Osmolality
 Sources: Diet, medications, IVF. The
minimum daily requirement is 2 grams
 Imbalances- Hyponatremia= <135 mEq/L;
Hypernatremia= >145 mEq/L

 retention in the kidney

Functions of Sodium:


 Participates in the Na-K pump
 Assists in maintaining blood volume
 Assists in nerve transmission and muscle contraction
 Primary determinant of ECF concentration.
 Controls water distribution throughout the body.
 Primary regulator of ECF volume.
 Sodium also functions in the establishment of the
electrochemical state necessary for muscle
contraction and the transmission of nerve impulses.
 Regulations: skin, GIT, GUT, Aldosterone increases Na
POTASSIUM
 The most abundant cation in the ICF
 Potassium is the major intracellular electrolyte; in
fact, 98% of the body’s potassium is inside the
cells.
 The remaining 2% is in the ECF; it is this 2% that is
all-important in neuromuscular function.
 Potassium is constantly moving in and out of cells
according to the body’s needs, under the
influence of the sodium-potassium pump.
 Normal range in the blood is 3.5-5 mEq/L
 Normal renal function is necessary for maintenance
of potassium balance, because 80-90% of the
potassium is excreted daily from the body by way
of the kidneys. The other less than 20% is lost
through the bowel and sweat glands.
 Major electrolyte maintaining ICF balance
 Sources- Diet, vegetables, fruits, IVF, medications

Functions:
 Maintains ICF Osmolality
 Important for nerve conduction and muscle
contraction
 Maintains acid-base balance
 Needed for metabolism of carbohydrates, fats and
proteins
 Potassium influences both skeletal and cardiac muscle
activity.
◦ For example, alterations in its concentration change
myocardial irritability and rhythm.
 Regulations: renal secretion and excretion,
Aldosterone promotes renal excretion acidosis
promotes K exchange for hydrogen
 Imbalances:
◦ Hypokalemia= <3.5 mEq/L
◦ Hyperkalemia=> 5.0 mEq/L

CALCIUM

 Majority of calcium is in the bones and teeth

 Small amount may be found in the ECF and
ICF
 Normal serum range is 8.5 – 10.5 mg/dL
 Sources: milk and milk products; diet; IVF
and medication
Functions of Calcium:

 1. Needed for formation of bones and

teeth
 2. For muscular contraction and
relaxation
 3. For neuronal and cardiac function
 4. For enzymatic activation
 5. For normal blood clotting

Regulations:

 1. GIT- absorbs Ca+ in the intestine; Vitamin D helps to

increase absorption
 2. Renal regulation- Ca+ is filtered in the glomerulus
and reabsorbed in the tubules:
 3. Endocrine regulation:
 Parathyroid hormone from the parathyroid glands is
released when Ca+ level is low. PTH causes release of
calcium from bones and increased retention of calcium
by the kidney but PO4 is excreted
 Calcitonin from the thyroid gland is released when the
calcium level is high. This causes excretion of both
calcium and PO4 in the kidney and promoted
deposition of calcium in the bones.
 Imbalances- Hypocalcemia= <8.5 mg/dL;
Hypercalcemia= >10.5 mg/dL

CHLORIDE

 The major Anion of the ECF

 Normal range is 95-108 mEq/L
 Sources: Diet, especially high salt foods, IVF
(like NSS), HCl (in the stomach)


Functions:

 1. Major component of gastric juice

 2. Regulates serum Osmolality and blood
volume
 3. Participates in the chloride shift
 4. Acts as chemical buffer
 Regulations: Renal regulation by absorption
and excretion; GIT absorption


 Imbalances: Hypochloremia= < 95 mEq/L;

Hyperchloremia= >108 mEq/L

PHOSPHATES

The major Anion of the ICF


 Normal range is 2.5 to 4.5 mg/dL
 Sources: Diet, TPN, Bone reserves
 


Functions:

 1. Component of bones, muscles and

nerve tissues
 2. Needed by the cells to generate ATP
 3. Needed for the metabolism of
carbohydrates, fats and proteins
 4. Component of DNA and RNA

 Regulations: Renal glomerular filtration,
endocrinal regulation by PTH-decreases
PO4 in the blood by kidney excretion

 Imbalances- Hypophosphatemia= <2.5
mg/dL; Hyperphosphatemia >4.5 mg/dL

BICARBONATES

 Present in both ICF and ECF

 Regulates acid-base balance together with
hydrogen
 Normal range is 22-26 mEq/L
 Sources: Diet; medications and metabolic by-
products of the cells.
 Function: Component of the bicarbonate-
carbonic acid buffer system
 Regulation: Kidney production, absorption and
secretion
 Imbalances: Metabolic acidosis= <22 mEq/L;
Metabolic alkalosis= >26 mEq/
  

Magnesium (1.5-2.5 mEq/L)
 Second most abundant ICF cation
 essential for neuromuscular function
 changes in serum Mg+ levels effect other
electrolytes
 excreted primarily by kidneys

42
ACID BASE BALANCE
 Alkalosis
 Acidosis

FACTORS AFFECTING BODY FLUID,
ELECTROLYTES & ACID-BASE
BALANCE

AGE
Infants have higher proportion of body water than adults
Water content of the body decreases with age
Infants have higher fluid turn-over due to immature kidney and rapid respiratory rate

 

 GENDER AND BODY SIZE

Women have higher body fat content but lesser water content

Lean body has higher water content

 

 ENVIRONMENT AND TEMPERATURE

Climate and heat and humidity affect fluid balance

 

 DIET AND LIFESTYLE

Anorexia nervosa will lead to nutritional depletion

Stressful situations will increase metabolism, increase ADH causing water retention and

increased blood volume

Chronic Alcohol consumption causes malnutrition

 ILLNESS
Trauma and burns release K+ in the blood

Cardiac dysfunction will lead to edema and congestion

 

 MEDICAL TREATMENT, MEDICATIONS AND SURGERY

Suctioning, diuretics and laxatives may cause imbalance
Fluid Volume
Disturbances
Fluid Volume Deficit (Hypovolemia)
Fluid Volume Excess (Hypervolemia)

45
Fluid Volume Deficit (Hypovolemia)
 Loss of body fluid or the shift of fluids into 3rd
space


 Common sources for fluid loss

◦ GI tract, polyuria, excessive perspiration, bleeding
 Related factors:
◦ inadequate fluid intake
◦ electrolyte & acid-base imbalances
◦ failure of regulatory mechanisms
◦ fluid shifts (edema or effusions)
 BUN will be elevated d/t low volume
◦ normal BUN = 10-25

46
Clinical manifestations
 Complaints of weakness and thirst
 Weight loss
◦ 2% loss = mild
◦ 5% loss = moderate
◦ 8% loss =severe
 Decreased skin turgor
 Dry mucous membrane, sunken eyeballs
 Decreased tearing
 Decreased blood pressure
 Weak, rapid pulse
 Flat neck vein, decreased capillary refill
 Decrease urine output(<30 ml/hr)
 Increase specific gravity (>1.030)
 Increase hematocrit
 Increase BUN

Nursing Responsibilities:
 monitor I & O frequently
 Provide frequent mouth care
 normal urinary output = 30 – 60 cc/hr
◦ check O2 sats & draw blood gases
◦ auscultate lungs (side to side)
◦ check temperature distal from heart
◦ give a fluid bolus as ordered
◦


48
HYPERVOLEMIA
 Excess of isotonic fluid in the intravascular and
interstitial spaces  third spacing
 Isotonic fluid retention is primarily r/t RF
 Hyperaldosteronism
 Iatrogenic hypervolemia: mistake made by health-
care staff…too much IV fluid!

49
Clinical manifestations
 Weight gain
◦ 2% gain = mild
◦ 5% gain = moderate
◦ 8% gain =severe
 Most crackles in lungs
 Dyspnea; shortness of breath
 Fluid intake greater than output
 Increase BP
 Full, bounding pulse;
 Tachycardia
 Mental confusion
Nursing Responsibilities:
 Monitor weight & v/s
 Assess for edema
 Assess for breath sounds
 Monitor laboratory findings
 Place in fowlers position
 Administer antidiuretics as ordered
 Restrict fluid intake
 Restrict dietary sodium as ordered
 Implement measures to prevent skin
breakdown
Hyperosmolar Imbalance

•Collaborative Management
•Fluid replacement
•Oral – safest route
•IVF – Dextrose in water, NSS
•I & O accurately
•Supportive care
•Treat fever
•Mouth care
•Treat primary cause
•Evaluation
•Awake and alert
•Urine output equals intake
Hypoosmolar Imbalance
•Etiology
•Excess intake of electrolyte –free fluid
•Increased secretion of ADH
•Na deficit (hypoaldosteronism)
•Assessment
change in mentation hyperventilation
sudden wt gain increased ICP(cushings)
sl peripheral edema low serum Na
•Collaborative Management
•Fluid restriction
•Diuretics & hypertonic saline infusion
•I & O accurately
•Monitor serum electrolytes
•Assess neurologic function
Isotonic Volume Imbalance
•Etiology
hemorrhage profuse sweating
vomiting/diarrhea third space loss
draining fistulas surgical openings
•Assessment
poor skin turgor dry mouth
postural hypotension low BP, tachy
poor venous filling low urine output
•Collaborative management
•Fluid replacement
•Supportive care
•Correct primary cause
Edema

Oncotic pressure Hydrostatic pressure

inward force outward force

Fluid in interstitial space

Effective circulating volume

Activation of RAAS

Retention of Na/water

EDEMA
Edema
•Types
•Pitting
•Nonpitting
•Assessment
weight gain
dependent edema
tight, smooth shiny skin cool pale skin
weeping edema
neck vein engorgement
uncomfortable garments effusion
•Collaborative management
•Na and fluid restrictions
•Diuretics
•High CHON diet
•Protection of edematous area from injury
•Promote venous return
•
Electrolyte Imbalances
Hypo and Hypernatremia
Hypo and Hyperkalemia
Hypo and Hypercalcemia
Hypo and Hypermagnesemia

57
Sodium (Na) 135-145 mEq/L
 Must be present for glucose to be transported into
cells
 Controls ECF osmotic pressure
 Necessary for neuromuscular functioning
 Determines intracellular reactions
 Maintains acid base balance


58
Hypernatremia
 Etiology
◦ High Na intake
◦ Salt tablets
◦ Rapid saline infusion
◦ Water deprivation
◦ Diarrhea

59
60
 Assessment
◦ Extreme thirst
◦ Dry sticky buccal mucosa
◦ Oliguria
◦ Firm, rubbery tissue turgor
◦ Red dry swollen tongue
◦ Tachycardia
◦ Fatigue
◦ Restlessness
◦ Hallucination

61
 Collaborative Management
◦ Restrict Na in diet
◦ Monitor I & O and behavioral changes
◦ Increase oral fluids or D5W/IV
◦ Diuretics
◦ Dialysis

62
Hyponatremia
 Etiology
◦ Treatment with diuretics
◦ Na restriction
◦ GI loss
◦ Decreased aldosterone
◦ Third space loss
◦ Diaphoresis

63
64
 Assessment
◦ Headache
◦ Muscle weakness
◦ Fatigue
◦ Postural hypotension
◦ Anorexia
◦ N/V
◦ Abdominal cramps
◦ Weight loss
◦ Seizure/coma

65
 Collaborative management
◦ IVF 0.9 NaCl/IV
◦ Replace other electrolytes needed
◦ Salty foods in diet
◦ Safety precaution

66
Potassium (K) 3.5-5 mEq/L
 Excitability of nerves and muscles
 ICF osmotic pressure
 Maintains acid-base balance
 K deficit: alkalosis
 K excess: acidosis
 Anabolism: K enters cell
 Catabolism: K leaves cell

67
Hypokalemia
 Etiology
◦ Decreases intake
◦ Increased loss
◦ Intracellular shift

68
Assessment


◦ Anorexia
◦ N/V
◦ Paralytic ileus
◦ CNS depression
◦ Muscle weakness
◦ Altered kidney function
◦ Dysrythmias

69
 Collaborative Management
 Potassium rich foods
◦ Banana
◦ dried fruits (raisins,prunes)
◦ orange
◦ raw carrot
◦ raw tomato
◦ baked potato
◦ melon
◦ watermelon
 Potassium supplement
◦ Oral: K durule tab 1-3 tabs daily
◦ IV incorporation/slow drip
 Potassium sparing diuretics

70
Hyperkalemia
Etiology
◦ Excess intake
◦ Retention of K
◦ Extracellular shift

71
 Assessment
◦ diarrhea
◦ N/V
◦ Numbness
◦ tingling sensation
◦ muscle irritability
◦ muscle paralysis
◦ Oliguria / anuria
◦ dysrhytmias

72
Collaborative management
◦ Avoid K-rich foods
◦ Promote bedrest
◦ 10% glucose with regular
insulin/IV
◦ Dialysis

73
HYPOCALCEMIA
 Calcium deficit or a total serum calcium
level of less than 8.5 mg/dL or an ionized
calcium level of less than 4.0 mg/dL
 Severe depletion of calcium can cause
tetany with muscle spasm and
paresthesias


 TWO SIGNS INDICATE HYPOCALCEMIA:

◦ Chvostek’s sign
◦ Trousseau’s sign
Hypocalcemia
 ETIOLOGY
◦ Surgical removal of the parathyroid glands
◦ Conditions such as
 Hypoparathyroidism
Acute pancreatitis
Hyperphosphatemia
Thyroid carcinoma
◦ Inadequate vitamin D intake
Malabsorption
Hypomagnesemia
Alkalosis
Sepsis
Alcohol abuse
hypocalcemia
 Assessment:
◦ Numbness, tingling of the extremities and
around the mouth
◦ Muscle tremors
◦ Cramps
◦ If severe can progress to tetany & convulsion
◦ Chvostek’s sign & trouseau’s sign
◦ Hyperactive deep tendon reflex
◦
hypocalcemia
 Intervention
◦ Closely monitor respiratory & cardiovascular
status
◦ Take precautions to protect a confused client
◦ Administer oral or parenteral calcium
supplements as ordered
◦ Health teaching: Client at High Risk for
Osteoporosis about
 Dietary sources rich in calcium
1000-1500 mg of calcium per day
Calcium supplements
Regular exercise
Estrogen therapy for post menopausal women
Hypercalcemia
 Total serum calcium levels greater than 10.5
mg/dL or an iodized calcium level of
greater than 5.0 mg/dL

Hypercalcemia
 Total serum calcium is greater than 10.5
mg/dL or an ionized calcium level of
greater than 5.0 mg/dL


 ETIOLOGY:
◦ Prolonged immobolization
◦ Hyperparathyroidism
◦ Malignancy of the bone
◦ Paget’s disease
hypercalcemia
 Assessment:
◦ Lethargy, weakness
◦ Depressed deep-tendon refelexes
◦ Bone pain
◦ Anorexia, nausea, vomiting
◦ Constipation
◦ Polyuria, hypercalciuria
◦ Flank pain secondary to urinary calculi

hypercalcemia
 Intervention:
◦ Increase client movement & exercise
◦ Encourage oral fluids as permitted to maintain a
dilute urine
◦ Teach clients to limit intake of food and fluid
high in calcium
◦ Encourage ingestion of fiber to prevent
constipation
◦ Protect a confused client
◦ Monitor for pathologic fracture in clients with
long-term
◦ Hypercalcemia
◦ Encourage intake of acid-ash fluids
magnesium
 HYPOMAGNESEMIA
◦ Magnesium deficiency
◦ Magnesium level of 1.5 mEq/L
 ETIOLOGY:
◦ Excessive loss from the gastrointestinal tract
(e.q. from nasogastric suction, diarrhea, fistula
drainage)
◦ Long-term use of certain drugs (e.q. Diuretics,
aminoglycosides antibiotics)
◦ Conditions such as
Chronic alcoholism
Pancreatitis
Burns
hypomagnesemia
 Assessment:
◦ Neuromuscular irritability with tremors
◦ Increase reflexes, tremors, convulsions
◦ Positive chvostek’s sign & trousseau’s sign
◦ Tachycardia, elevate blood pressure
◦ Dysrhythmias
◦ Disorientation & confusion
◦ Vertigo
◦ Anorexia, dysphagia
◦ Respiratory difficulties
◦
hypomagnesemia
 Intervention:
◦ Take protective measures when there is a possibility
of seizures
◦
Assess the client’s ability to swallow water prior to
initiating oral feeding
Initiate safety measures to prevent injury during
seizure activity
Carefully administer magnesium salts as ordered.

◦ Encourage clients to eat magnesium-rich foods if
permitted
◦ Refer clients to alcohol treatment programs as
indicated
hypermagnesemia
 ETIOLOGY:
◦ Abnormal retention of magnesium, as in
Renal failure
Adrenal insufficiency
Treatment with magnesium salts


hypermagnesemia
 Assessment:
◦ Peripheral vasodilation
◦ Flushing
◦ Nausea, vomiting
◦ Muscle weakness, paralysis
◦ Hypotension, bradycardia
◦ Depressed deep tendon reflexes
◦ Lethargy, drowsiness
◦ Respiratory and cardiac arrest
◦ Respiratory depression, coma
◦

hypermagnesemia
 Nursing intervention:
◦ Monitor vital signs and level consciousness
◦ If patellar reflexes are absent, notify the primary
care provider
◦ Advise patient regarding over the counter drugs
ACID-BASE
IMBALANCES
RESPIRATORY ACIDOSIS
 Hypoventilation
 Carbon dioxide retention
 Etiology:
◦ CNS depression
◦
RESPIRATORY ALKALOSIS
 HYPERVENTILATION
 ETIOLOGY:
◦ Fever
◦ Respiratory illness
◦
Metabolic acidosis
 Bicarbonate levels are low
 Etiology:
◦ Renal failure
◦ Diabetic ketoacidosis
◦
Metabolic alkalosis
 The amount of bicarbonate exceeds the
normal
 Etiology:
◦ Excessive losses due
Vomiting
Gastric suction
Excessive use of potassium losing diuretics
Regulation of Acid-Base
 Buffers:
 Carbonic Acid
◦ Carbon dioxide dissolved in plasma
 Serum bicarbonate (HCO3)
◦ Major extracellular buffer in the blood.
◦ Kidneys regulate its generation and excretion.

93
Arterial Blood Gas Analysis
 Normal Values:
 pH - 7.35-3.45
 pCO2 - 35-45 mmHg
 HCO3 - 22-26 mEq/L


94
 Steps in ABG Analysis:
 Determine the pH
◦ Low – Acidic
◦ High – Basic
 Determine the area affected
◦ Lungs – Respiratory
◦ Kidneys - Metabolic
 Determine the level of compensation
◦ Uncompensated
◦ Partially compensated
◦ Fully compensated


95
Interpretation Arterial Blood
Gases
 If acidosis the pH is down

 If alkalosis the pH is up
 The respiratory function indicator is the PCO2
 The metabolic function indicator is the HCO3
Step 1

 Look at the pH
 Is it up or down?
 If it is up - it reflects alkalosis
 If it is down - it reflects acidosis
Step 2

 Look at the PCO2

 Is it up or down?
 If it reflects an opposite response as the pH,
◦ then you know that the condition is a respiratory imbalance
If it does not reflect an opposite response as the pH - move to step III

Step 3

 Look at the HCO3

 Does the HCO3 reflect a corresponding
 response with the pH
 If it does then the condition is a metabolic imbalance
  

PHYSICAL
ASSESSMENT
ASSESSMENT
 Current & past medical history
 Medications & treatment
 Food & fluid intake
 Fluid output
 Fluid, electrolyte, and acid base imbalances
 v/s
 Laboratory tests

Diagnosis
 Deficient fluid volume
 Excess fluid volume
 Risk for Imbalanced fluid volume
 Risk for deficient fluid volume
 Impaired gas exchange
 Impaired oral Mucous Membrane
 Impaired skin integrity
 Decreased cardiac output
 Ineffective tissue perfusion
 Activity intolerance
 Risk for injury
 Acute Confusion

Planning
 Maintain or restore normal fluid balance
 Maintain or restore normal balance of
electrolytes in the intracellular
compartments
 Maintain or restore pulmonary ventilation &
oxygenation
 Prevent associated risks
◦ Acid-base management
◦ Electrolyte management
◦ Fluid monitoring
◦ Hypovolemia management
◦ IV therapy
Nursing Sample indicators Selected Sample
diagnosis desired interventions activities
outcomes/ /definition
definition
INTRAVENOUS
FLUIDS
THERAPY
DEFINITION
 Intravenous (IV) Therapy is the
insertion of a needle or
catheter /cannula into a vein,
based on the physician’s written
prescription. The needle or
catheter/cannula is attached to a
sterile tubing and a fluid container
to provide medication and fluids.

INDICATIONS
1.To maintain hydration and/ or correct
dehydration in patients unable to tolerate
sufficient volumes of oral fluids/medications.
2.Parenteral Nutrition
3.Administration of drugs. Ex: chemotherapy,
other drugs
4.Transfusion of blood or blood components

FACTORS TO CONSIDER FOR IV
THERAPHY
 Duration of therapy
 Canuula size
 Condition of the vein/skin
 Type of solution
 Patient’s level of consciousness
 Patient’s acitivity
 Patient’s age
 Dominant arm
 Clinical status of patient

3 TYPES OF FLUIDS
Isotonic Fluids Ex: Lactated Ringer's
(LR), NS (normal saline,
or 0.9% saline in water).
Hypotonic fluids Ex: 45% NaCl, 2.5%
dextrose

Hypertonic fluids Ex: D5% .45% NaCl,

D5% LR, D5% NS, blood
products, and albumin.
ISOTONIC FLUID
Close to the same osmolarity as
serum. They stay inside the
intravascular compartment, thus
expanding it. Can be helpful in
hypotensive or hypovolemic patients.

Can be harmful. There is a risk of fluid

overloading, especially in patients
with CHF and hypertension

Isotonic fluids contain an approximately equal number of molecules

(blue dots) as serum so the fluid stays within the intravascular space.
Remember that fluid flows from an area of lower concentration of
molecules to an area of high concentration of molecules (osmosis) to
achieve equilibrium (fluid balance). In this example, there is no fluid flow
into or out of the intravascular space.
HYPOTONIC SOLUTIONS

Have less osmolarity than serum (i.e., it has less sodium

ion concentration than serum). It dilutes the serum,
which decreases serum osmolarity. Water is then pulled
from the vascular compartment into the interstitial fluid
compartment. Then, as the interstitial fluid is diluted, its
osmolarity decreases which draws water into the
adjacent cells. Can be helpful when cells are
dehydrated such as a dialysis patient on diuretic
therapy. May also be used for hyperglycemic conditions
like diabetic ketoacidosis, in which high serum glucose
levels draw fluid out of the cells and into the vascular
and interstitial compartments.
Can be dangerous to use because of the sudden fluid
shift from the intravascular space to the cells. This can
cause cardiovascular collapse and increased
intracranial pressure (ICP) in some patients.
HYPERTONIC FLUIDS


Have a higher osmolarity than serum. Pulls fluid and
electrolytes from the intracellular and interstitial
compartments into the intravascular compartment. Can
help stabilize blood pressure, increase urine output, and
reduce edema.  Rarely used in the prehospital setting.
Care must be taken with their use. Dangerous in the
setting of cell dehydration.
2 main groups of fluids

Crystalloid Ex: Lactated Ringer's

(LR), NS (normal saline).

Colloid Ex: albumin and steroids

TECHNIQUE
 Remember the four rights:
 Do I have the right patient?
 Do I have the right solution?
 Do I have the right drug?
 Do I have the right route?
IV DEVICES
Butterfly catheter. They are named after the wing-
like plastic tabs at the base of the needle. They are
used to deliver small quantities of medicines, to
deliver fluids via the scalp veins in infants, and
sometimes to draw blood samples (although not
routinely, since the small diameter may damage
blood cells). These are small gauge needles (i.e. 23
gauge).

peripheral IV catheter. This is the kind of catheter primarily be using.

Catheters (and needles) are sized by their diameter, which is called the
gauge. The smaller the diameter, the larger the gauge. Therefore, a
22-gauge catheter is smaller than a 14-gauge catheter. Obviously, the
greater the diameter, the more fluid can be delivered. To deliver large
amounts of fluid, you should select a large vein and use a 14 or 16-
gauge catheter. To administer medications, an 18 or 20-gauge catheter
in a smaller vein will do.
PREPARATION
 Absorbent disposable sheet
 1 alcohol prep pad
 1 betadine swab
 Tourniquet
 IV catheter
 IV tubing
 Bag of IV fluid
 4 pieces of tape (preferably paper tape or easy to
remove tape which has been precut to
approximately 4 inches (10cm) in length and
taped conveniently to the table or stretcher.
 Disposable gloves
 Gauze (several pieces of 4x4 or 2x2)

Prepare the IV fluid administration set

 Inspect the fluid bag

to be certain it
contains the desired
fluid, the fluid is
clear, the bag is not
leaking, and the bag
is not expired.
 Select either a mini or macro drip administration set
and uncoil the tubing. Do not let the ends of the
tubing become contaminated.
 Close the flow regulator (roll the wheel away from
the end you will attach to the fluid bag).
 Remove the protective covering from the port of the
fluid bag and the protective covering from the
spike of the administration set.
 Insert the spike of the administration set into the port
of the fluid bag with a quick twist. Do this carefully.
Be especially careful to not puncture yourself!
 Hold the fluid bag higher
than the drip chamber of
the administration set.
Squeeze the drip
chamber once or twice to
start the flow. Fill the drip
chamber to the marker
line (approximately one-
third full). If you overfill
the chamber, lower the
bag below the level of
the drip chamber and
squeeze some fluid back
into the fluid bag.
 Open the flow regulator and allow the fluid
to flush all the air from the tubing. Let it
run into a trash can or even the (now
empty) wrapper the fluid bag came in. You
may need to loosen or remove the cap at
the end of the tubing to get the fluid to
flow although most sets now allow flow
without removal. Take care not to let the
tip of the administration set become
contaminated.
 Turn off the flow and place the sterile cap
back on the end of the administration set
(if you've had to remove it). Place this end
nearby so you can reach it when you are
ready to connect it to the IV catheter in the
patient's vein.
VEIN SELECTION

Veins of the Hand

1. Digital Dorsal veins
2. Dorsal Metacarpal veins
3. Dorsal venous network
4. Cephalic vein
5. Basilic vein
Veins of the Forearm
1. Cephalic vein
2. Median Cubital vein
3. Accessory Cephalic vein
4. Basilic vein
5. Cephalic vein
6. Median antebrachial vein
PERFORMING VENIPUNCTURE

 Be sure you have introduced yourself to your patient and

explained the procedure.
 Apply a tourniquet high on the upper arm. It should be tight
enough to visibly indent the skin, but not cause the patient
discomfort. Have the patient make a fist several times in
order to maximize venous engorgement. Lower the arm to
increase vein engorgement.
 Select the appropriate vein. If you cannot easily see a suitable
vein, you can sometimes feel them by palpating the arm
using your fingers (not your thumb) The vein will feel like an
elastic tube that "gives" under pressure. Tapping on the
veins, by gently "slapping" them with the pads of two or
three fingers may help dilate them. If you still cannot find
any veins, then it might be helpful to cover the arm in a
warm, moist  compress to help with peripheral
vasodilatation. If after a meticulous search no veins are
found, then release the tourniquet from above the elbow
and place it around the forearm and search in the distal
forearm, wrist and hand. If still no suitable veins are found,
then you will have to move to the other arm. Be careful to
stay away from arteries, which are pulsatile
 Don disposable gloves. Clean the entry site carefully
with the alcohol prep pad. Allow it to dry. Then use
a betadine swab. Allow it to dry. Use both in a
circular motion starting with the entry site and
extending outward about 2 inches. (Using alcohol
after betadine will negate the effect of the
betadine) Note that some facilities may require an
alcohol prep without betadine or sometimes
alcohol after betadine. Go with the rules for your
facility.
 To puncture the vein, hold the catheter in your dominant hand.
With the bevel up, enter the skin at about a 30 degree angle
and in the direction of the vein. Use a quick, short,  jabbing
motion. After entering the skin, reduce the angle of the
catheter until it is nearly parallel to the skin. If the vein
appears to "roll" (move around freely under the skin), begin
your venipuncture by apply counter tension against the skin
just below  the entry site using your nondominant hand.
Many people use their thumb for this. Pull the skin distally
toward the wrist in the opposite direction the needle will be
advancing. Be carefully not to press too hard which will
compress blood flow in the vein and cause the vein to
collapse. Then pierce the skin and enter the vein as above.
 Advance the catheter to enter the vein until blood is seen in
the "flash chamber" of the catheter
•Aft er ent ering t he vein, advance t he plast ic cat het er
(which is over t he needle) on int o t he vein w hile
leaving t he needle st at ionary. The hub of t he cat het er
should be all t he w ay t o t he skin punct ure sit e. The
plast ic cat het er should slide forw ard easily. Do not
force it ! !
 Release the tourniquet.
 Apply gentle pressure over the vein just proximal to the entry
site to prevent blood flow. Remove the needle from within
the plastic catheter. Dispose of the needle in an appropriate
sharps container. NEVER reinsert the needle into the
plastic catheter while it is in the patient's arm!
Reinserting the needle can shear off the tip of the
plastic catheter causing an embolus. Remove the
protective cap from the end of the administration set and
connect it to the plastic catheter. Adjust the flow rate as
desired.
 Tape the catheter in place using the strips of tape and a
sterile 2X2 or a clear dressing. It is advisable not to use
the "chevron" taping technique.
 Label the IV site with the date, time, and your initials.
 Monitor the infusion for proper flow into the vein (in other
words, watch for infiltration).
Flow Rates
 Microdrip sets  Allow 60 drops (gtts) / mL
through a small needle into the drip
chamber


 Macrodrip sets  Allow 10 to 15 drops / mL

into the drip chamber
IV FLUID FLOW RATE
 ggts/min = volume in cc x ggt factor
 ---------------------------------
 no. of hours x 60 mins


 cc/hr = volume in cc
 -----------------
 no. of hours OR


 = ggts/min x 4


 Duration in hrs = volume in cc

 -----------------
 cc/hr



SAMPLE PROBLEMS
 The physician orders : Administer D5LR 3L for
24 hours


A.How many ggts/min will you regulate the IVF

B.How many mls per hour will be infused?



COMPUTATION
A.ggts/ min = vol. inn cc x ggt factor
 ----------------------------
 no of hrs x 60 mins


 = 3,000 cc x 15
 ------------------
 24 hrs x 60 mins


 = 45,000
 --------
 1,440


 = 31 gtts/min

B.

cc/hr = vol in cc
 ---------------
 no. of hrs


 = 3,000 cc
 --------------
 24 hrs


 = 125 cc/hr.



SAMPLE PROBLEMS
Start IVF @ 7 am D5LR 1L to run for 12
hours.
A.Compute cc/hr
B.Solve level at 10 am
C.@ 12 noon plus cc consumed
D.Consumed at what time

ANSWER
A.Vol in cc 1000 cc
 ------------ = ----------- = 83 cc/hr
 No. of hrs. 12 hrs


B. Solve for level at 10 Am D. consumed at what time

 = 83 x 3 = 249 7 pm
 = 1000 cc
 - 249
 =======
 751 cc


C.12 noon, plus cc consumed

 83cc x 5 = 415 cc
No. of 250 ml 500 ml 1000 ml

Hours gtts/min mcgtts/min cc/hr gtts/min mcgtts/min cc/hr gtts/min mcgtts/min cc/hr
4 17 62 62 31 125 125 63 250 250
5 12 50 50 25 100 100 50 200 200
6 10 41 41 20 83 83 42 167 167
7 9 36 36 18 71 71 36 143 143
8 9 31 31 16 62 62 31 125 125
9 7 28 28 14 56 56 28 111 111
10 6 25 25 12 50 50 25 100 100
11 6 23 23 11 44 44 23 91 91
12 5 21 21 10 42 42 21 83 83
13 5 19 19 10 40 40 18 77 77
14 4 18 18 8 36 36 18 71 71
15 4 17 17 8 33 33 17 66 66
16 4 16 16 7 31 31 16 62 62
17 4 15 15 7 29 29 15 59 59
18 3 14 14 7 28 28 14 56 56
19 3 13 13 6 26 26 13 53 53
20 3 12 12 6 25 25 13 50 50
21 3 12 12 6 24 24 12 48 48
22 3 12 12 6 24 24 12 46 46
23 3 12 12 5 22 22 11 44 44
24 3 10 10 5 21 21 10 42 42
END
Thank you!