FLUIDS & ELECTROLYTES

JENNIFER H. MESDE, RN, MAN

I. ADULTS

a. Women: 50-55% body weight is waterb. Men: 60-70% body weight is waterc. Elderly: 47% body weight is water

II. INFANTS75-80% body weight is water

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 fluida. Interstitial - 75%b. Intravascular (plasma) - 20%c. Other: cerebrospinal fluid, intraocular fluid,

bone water, gastrointestinal secretions

DISTRIBUTION OF BODY FLUIDS

IONS◦ Charge particles

ELECTROLYTES◦ Charge particles◦ They are capable of conducting energy

Cations – positive charge ions

Anions – negative charge ions

COMPOSITION OF BODY BLUIDS

ELECTROLYTES◦ Extracellular

a. Sodium (Na+) 135-145 mEq/lb. Calcium (Ca++) 8-10 mg/dlc. Chloride (Cl-) 85-145 mEq/ld. Bicarbonate (HCO3

-) 22-29 mEq/l

◦ Intracellulara. Potassium (K+) 3.5-5.5 mEq/lb. Phosphate (PO4) 2.5-4.5 mg/dl

c. Magnesium (Mg+) 1.3 -2.0 mEq/l

COMPOSITION OF BODY FLUIDS

ELECTROLYTE COMPOSITION

a. Promote neuromuscular excitabilityb. Maintain fluid volumec. Distribute water between fluid

compartmentsd. Regulate acid-base balance

Functions of Electrolytes

OSMOSIS

◦ the movement of water across cell membranes from the less concentrated solution to the more concentrated solution

MOVEMENT OF FLUIDS & ELECTROLYTES

osmosis

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

OSMOLALITY

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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.

diffusion

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

FILTRATION

Substance move across cell membranes from a less concentrated one

The sodium-potassium pump

ACTIVE TRANSPORT

AVERAGE DAILY FLUID INTAKE OF AN ADULT

SOURCE

Oral fluidsWater in foodsWater-as-by-products of food metabolism

Total

AMOUNT (ML)

1,200 to 1,5001,000200

2,400 to 2,700

REGULATING BODY FLUIDS

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

Fluid intake

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.

Kidneys Antidiuretic Hormones Renin-Angiotensin-Aldosterone System Atrial Natriuretic Factor (ANF)

MAINTAINING HOMEOSTASIS

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

KIDNEYS

ADH

Renin-Angiotensin-Aldosterone System

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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

REGULATING ELECTROLYTES

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

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

Functions of Sodium:

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

POTASSIUM

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

Functions:

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

CALCIUM

1. Needed for formation of bones and teeth2. For muscular contraction and relaxation3. For neuronal and cardiac function4. For enzymatic activation5. For normal blood clotting

Functions of Calcium:

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

2. Renal regulation- Ca+ is filtered in the glomerulus andreabsorbed 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

Regulations:

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)

CHLORIDE

1. Major component of gastric juice2. Regulates serum Osmolality and blood volume3. Participates in the chloride shift4. Acts as chemical buffer

Functions:

Regulations: Renal regulation by absorption and excretion; GIT absorption

Imbalances: Hypochloremia= < 95 mEq/L; Hyperchloremia= >108 mEq/L

The major Anion of the ICF Normal range is 2.5 to 4.5 mg/dL Sources: Diet, TPN, Bone reserves 

PHOSPHATES

1. Component of bones, muscles and nerve tissues2. Needed by the cells to generate ATP3. Needed for the metabolism of carbohydrates, fats and proteins4. Component of DNA and RNA

Functions:

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

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/  

BICARBONATES

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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

Alkalosis Acidosis

ACID BASE BALANCE

AGEInfants have higher proportion of body water than adultsWater content of the body decreases with ageInfants have higher fluid turn-over due to immature kidney and rapid respiratory rate 

GENDER AND BODY SIZEWomen have higher body fat content but lesser water contentLean body has higher water content 

ENVIRONMENT AND TEMPERATUREClimate and heat and humidity affect fluid balance 

DIET AND LIFESTYLEAnorexia nervosa will lead to nutritional depletionStressful situations will increase metabolism, increase ADH causing water retention and

increased blood volumeChronic Alcohol consumption causes malnutrition

ILLNESSTrauma and burns release K+ in the bloodCardiac dysfunction will lead to edema and congestion 

MEDICAL TREATMENT, MEDICATIONS AND SURGERYSuctioning, diuretics and laxatives may cause imbalance

FACTORS AFFECTING BODY FLUID, ELECTROLYTES & ACID-BASE BALANCE

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Fluid Volume Disturbances

Fluid Volume Deficit (Hypovolemia)Fluid Volume Excess (Hypervolemia)

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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

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

Clinical manifestations

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Nursing Responsibilities:

monitor I & O frequently Provide frequent mouth carenormal 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

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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!

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

Clinical manifestations

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

Nursing Responsibilities:

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)

•Assessmentchange in mentation hyperventilationsudden 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 sweatingvomiting/diarrhea third space lossdraining fistulas surgical

openings•Assessment

poor skin turgor dry mouthpostural hypotension low BP, tachypoor venous filling low urine output

•Collaborative management• Fluid replacement• Supportive care• Correct primary cause

Edema

Oncotic pressure

inward force

Fluid in interstitial space

Effective circulating volume

Activation of RAAS

Retention of Na/water

EDEMA

Hydrostatic pressure

outward force

Edema •Types

• Pitting• Nonpitting

•Assessmentweight gaindependent edematight, smooth shiny skin cool pale skinweeping edemaneck vein engorgementuncomfortable garments effusion

•Collaborative management• Na and fluid restrictions• Diuretics• High CHON diet• Protection of edematous area from injury• Promote venous return

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Electrolyte ImbalancesHypo and HypernatremiaHypo and HyperkalemiaHypo and Hypercalcemia

Hypo and Hypermagnesemia

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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

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Hypernatremia

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

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

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

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Hyponatremia

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

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

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

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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

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Hypokalemia

Etiology◦Decreases intake◦Increased loss◦Intracellular shift

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Assessment

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

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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

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Hyperkalemia

Etiology◦Excess intake◦Retention of K◦Extracellular shift

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

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

◦Dialysis

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

hypocalcemia

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

hypercalcemia

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

magnesium

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

hypomagnesemia

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

hypermagnesemia

ACID-BASE IMBALANCES

Hypoventilation Carbon dioxide retention Etiology:

◦ CNS depression

RESPIRATORY ACIDOSIS

HYPERVENTILATION ETIOLOGY:

◦ Fever◦ Respiratory illness

RESPIRATORY ALKALOSIS

Bicarbonate levels are low Etiology:

◦ Renal failure◦ Diabetic ketoacidosis

Metabolic acidosis

The amount of bicarbonate exceeds the normal

Etiology:◦ Excessive losses due

Vomiting Gastric suction Excessive use of potassium losing diuretics

Metabolic alkalosis

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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.

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Arterial Blood Gas Analysis

Normal Values: pH - 7.35-3.45 pCO2 - 35-45 mmHg HCO3 - 22-26 mEq/L

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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

 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 HCO3Step 1 Look at the pH Is it up or down? If it is up - it reflects alkalosis If it is down - it reflects acidosisStep 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 IIIStep 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  

Interpretation Arterial Blood Gases

PHYSICAL ASSESSMENT

Current & past medical history Medications & treatment Food & fluid intake Fluid output Fluid, electrolyte, and acid base imbalances v/s Laboratory tests

ASSESSMENT

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

Diagnosis

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

Planning

Nursing diagnosis

Sample desired outcomes/ definition

indicators Selected interventions/definition

Sample activities

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 Nutrition3. Administration of drugs. Ex: chemotherapy,

other drugs4. 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

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.

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

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 Hand1. Digital Dorsal veins2. Dorsal Metacarpal veins3. Dorsal venous network4. Cephalic vein5. Basilic vein

Veins of the Forearm1. Cephalic vein2. Median Cubital vein3. Accessory Cephalic vein4. Basilic vein5. Cephalic vein6. 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

• After entering the vein, advance the plastic catheter (which is over the needle) on into the vein while leaving the needle stationary. The hub of the catheter should be all the way to the skin puncture site. The plastic catheter should slide forward 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 IVFB. How many mls per hour will be infused?

COMPUTATIONA. 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/hrB. Solve level at 10 amC. @ 12 noon plus cc consumedD. Consumed at what time

ANSWERA. Vol in cc 1000 cc

------------ = ----------- = 83 cc/hrNo. 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 consumed83cc 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

ENDThank you!