What are IV Fluids?
Intravenous fluids (IV Fluids), also known as intravenous solutions, are
supplemental fluids used in intravenous therapy to restore or maintain normal
fluid volume and electrolyte balance when the oral route is not possible. IV fluid
therapy is an efficient and effective way of supplying fluids directly into the
intravascular fluid compartment, in replacing electrolyte losses, and in
administering medications and blood products.
Types of IV Fluids
There are different types of IV fluids and different ways on how to classify them.
The most common way to categorize IV fluids is based on their tonicity:
• Isotonic. Isotonic IV solutions that have the same concentration of
solutes as blood plasma.
• Hypotonic. Hypotonic solutions have lesser concentration of solutes
than plasma.
• Hypertonic. Hypertonic solutions have greater concentration of
solutes than plasma.
IV solutions can also be classified based on their purpose:
• Nutrient solutions. May contain dextrose, glucose, and levulose to
make up the carbohydrate component – and water. Water is
supplied for fluid requirements and carbohydrate for calories and
energy. Nutrient solutions are useful in preventing dehydration and
ketosis. Examples of nutrient solutions include D5W, D5NSS.
• Electrolyte solutions. Contains varying amounts of cations and
anions that are used to replace fluid and electrolytes for clients with
continuing losses. Examples of electrolyte solutions include 0.9 NaCl,
Ringer’s Solution, and LRS.
• Alkalinizing solutions. Are administered to treat metabolic acidosis.
Examples: LRS.
• Acidifying solutions. Are used to counteract metabolic alkalosis.
D51/2NS, 0.9 NaCl.
• Volume expanders. Are solutions used to increase the blood
volume after a severe blood loss, or loss of plasma. Examples of
volume expanders are dextran, human albumin, and plasma.
Crystalloids
Crystalloid IV solutions contain small molecules that flow easily across
semipermeable membranes. They are categorized according to their relative
tonicity in relation to plasma. There are three types: isotonic, hypotonic, and
hypertonic.
Isotonic IV Fluids
Most IV fluids are isotonic, meaning, they have the same concentration of
solutes as blood plasma. When infused, isotonic solutions expand both the
intracellular fluid and extracellular fluid spaces, equally. Such fluids do not alter
the osmolality of the vascular compartment. Technically, electrolyte solutions are
considered isotonic if the total electrolyte content is approximately 310 mEq/L.
Isotonic IV fluids have a total osmolality close to that of the ECF and do not cause
red blood cells to shrink or swell.
Cheat sheet for Isotonic IV Fluids.
0.9% NaCl (Normal Saline Solution, NSS)
Normal saline solution (0.9% NaCl) or NSS, is a crystalloid isotonic IV fluid that
contains water, sodium (154 mEq/L), and chloride (154 mEq/L). It has an
osmolality of 308 mOsm/L and gives no calories. It is 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. Normal saline is the isotonic solution of choice for expanding the
extracellular fluid (ECF) volume because it does not enter the intracellular fluid
(ICF). It is administered to correct extracellular fluid volume deficit because it
remains within the ECF.
Normal saline is the IV fluid used alongside the administration of blood products.
It is also used to replace large sodium losses such as in burn injuries and trauma.
It should not be used for heart failure, pulmonary edema, and renal impairment,
or conditions that cause sodium retention as it may risk fluid volume overload.
Dextrose 5% in Water (D5W)
D5W (dextrose 5% in water) is a crystalloid isotonic IV fluid with a serum
osmolality of 252 mOsm/L. D5W is initially an isotonic solution and provides free
water when dextrose is metabolized (making it a hypotonic solution), expanding
the ECF and the ICF. It is administered to supply water and to correct an increase
in serum osmolality. A liter of D5W provides fewer than 200 kcal and contains
50g of glucose. It should not be used for fluid resuscitation because
hyperglycemia can result. It should also be avoided to be used in clients at risk
for increased intracranial pressure as it can cause cerebral edema.
Lactated Ringer’s 5% Dextrose in Water (D5LRS)
Lactated Ringer’s Solution (also known as Ringer’s Lactate or Hartmann
solution) is a crystalloid isotonic IV fluid designed to be the near-physiological
solution of balanced electrolytes. It contains 130 mEq/L of sodium, 4 mEq/L
of potassium, 3 mEq/L of calcium, and 109 mEq/L of chloride. It also contains
bicarbonate precursors to prevent acidosis. It does not provide calories
or magnesium and has limited potassium replacement. It 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.
Lactated Ringer’s is used to correct dehydration, sodium depletion, and replace
GI tract fluid losses. It can also be used in fluid losses due to burns, fistula
drainage, and trauma. It is the choice for first-line fluid resuscitation for certain
patients. It is often administered to patients with metabolic acidosis.
Lactated Ringer’s solution is metabolized in the liver, which converts the lactate
to bicarbonate, therefore, it should not be given to patients who cannot
metabolize lactate (e.g., liver disease, lactic acidosis). It should be used in caution
for patients with heart failure and renal failure.
Ringer’s Solution
Ringer’s solution is another isotonic IV solution that has content similar to
Lactated Ringer’s Solution but does not contain lactate. Indications are the same
for Lactated Ringer’s but without the contraindications related to lactate.
Nursing Considerations for Isotonic IV Solutions
The following are the general nursing interventions and considerations when
administering isotonic solutions:
• Document baseline data. Before infusion, assess the patient’s vital
signs, edema status, lung sounds, and heart sounds. Continue
monitoring during and after the infusion.
• Observe for signs of fluid overload. Look for signs of hypervolemia
such as hypertension, bounding pulse, pulmonary crackles, dyspnea,
shortness of breath, peripheral edema, jugular venous distention,
and extra heart sounds.
• Monitor manifestations of continued hypovolemia. Look for
signs that indicate continued hypovolemia such as, decreased urine
output, poor skin turgor, tachycardia, weak pulse, and hypotension.
• Prevent hypervolemia. Patients being treated for hypovolemia can
quickly develop fluid overload following rapid or over infusion of
isotonic IV fluids.
• Elevate the head of the bed at 35 to 45 degrees. Unless
contraindicated, position the client in semi-Fowler’s position.
• Elevate the patient’s legs. If edema is present, elevate the legs of
the patient to promote venous return.
• Educate patients and families. Teach patients and families to
recognize signs and symptoms of fluid volume overload. Instruct
patients to notify their nurse if they have trouble breathing or notice
any swelling.
• Close monitoring for patients with heart failure. Because isotonic
fluids expand the intravascular space, patients with hypertension and
heart failure should be carefully monitored for signs of fluid
overload.
Hypotonic IV Fluids
Hypotonic IV solutions have a lower osmolality and contain fewer solutes than
plasma. They cause fluid shifts from the ECF into the ICF to achieve homeostasis,
therefore, causing cells to swell and may even rupture. IV solutions are
considered hypotonic if the total electrolyte content is less than 250 mEq/L.
Hypotonic IV fluids are usually used to provide free water for excretion of body
wastes, treat cellular dehydration, and replace the cellular fluid.
0.45% Sodium Chloride (0.45% NaCl)
Sodium chloride 0.45% (1/2 NS), also known as half-strength normal saline, is
a hypotonic IV solution used for replacing water in patients who have
hypovolemia with hypernatremia. Excess use may lead to hyponatremia due to
the dilution of sodium, especially in patients who are prone to water retention. It
has an osmolality of 154 mOsm/L and contains 77 mEq/L sodium and chloride.
Hypotonic sodium solutions are used to treat hypernatremia and other
hyperosmolar conditions.
0.33% Sodium Chloride (0.33% NaCl)
Cheat sheet for Hypotonic IV Fluids.
0.33% Sodium Chloride Solution is used to allow kidneys to retain the needed
amounts of water and is typically administered with dextrose to increase tonicity.
It should be used in caution for patients with heart failure and renal insufficiency.
0.225% Sodium Chloride (0.225% NaCl)
0.225% Sodium Chloride Solution is often used as a maintenance fluid for
pediatric patients as it is the most hypotonic IV fluid available at 77 mOsm/L.
Used together with dextrose.
2.5% Dextrose in Water (D2.5W)
Another hypotonic IV solution commonly used is 2.5% dextrose in water
(D2.5W). This solution is used to treat dehydration and decreased the levels of
sodium and potassium. It should not be administered with blood products as it
can cause hemolysis of red blood cells.
Nursing Considerations for Hypotonic IV Solutions
The following are the general nursing interventions and considerations when
administering hypotonic IV solutions:
• Document baseline data. Before infusion, assess the patient’s vital
signs, edema status, lung sounds, and heart sounds. Continue
monitoring during and after the infusion.
• Do not administer in contraindicated conditions. Hypotonic
solutions may exacerbate existing hypovolemia
and hypotension causing cardiovascular collapse. Avoid use in
patients with liver disease, trauma, or burns.
• Risk for increased intracranial pressure (IICP). Should not be
given to patients with risk for IICP as the fluid shift may cause
cerebral edema (remember: hypotonic solutions make cells swell).
• Monitor for manifestations of fluid volume deficit. Signs and
symptoms include confusion in older adults. Instruct patients to
inform the nurse if they feel dizzy.
• Warning on excessive infusion. Excessive infusion of hypotonic IV
fluids can lead to intravascular fluid depletion, decreased blood
pressure, cellular edema, and cell damage.
• Do not administer along with blood products. Most hypotonic
solutions can cause hemolysis of red blood cells especially during
rapid infusion of the solution.
Hypertonic IV Fluids
Hypertonic IV solutions have a greater concentration of solutes (375 mEq/L and
greater) than plasma and cause fluids to move out of the cells and into the ECF in
order to normalize the concentration of particles between two compartments.
This effect causes cells to shrink and may disrupt their function. They are also
known as volume expanders as they draw water out of the intracellular space,
increasing extracellular fluid volume.
Cheat sheet for
Hypertonic IV Fluids.
Hypertonic Sodium Chloride IV Fluids
Hypertonic sodium chloride solutions contain a higher concentration of sodium
and chloride than normally contained in plasma. Infusion of hypertonic sodium
chloride solution shifts fluids from the intracellular space into the intravascular
and interstitial spaces. Hypertonic sodium chloride IV solutions are available
in the following forms and strengths:
• 3% sodium chloride (3% NaCl) containing 513 mEq/L of sodium
and chloride with an osmolality of 1030 mOsm/L.
• 5% sodium chloride (5% NaCl) containing 855 mEq/L of sodium
and chloride with an osmolality of 1710 mOsm/L.
Hypertonic sodium chloride solutions are used in the acute treatment of sodium
deficiency (severe hyponatremia) and should be used only in critical situations to
treat hyponatremia. They need to be infused at a very low rate to avoid the risk of
overload and pulmonary edema. If administered in large quantities and rapidly,
they may cause an extracellular volume excess and precipitate circulatory
overload and dehydration. Therefore, they should be administered cautiously and
usually only when the serum osmolality has decreased to critically low
levels. Some patients may need diuretic therapy to assist in fluid excretion. It is
also used in patients with cerebral edema.
Hypertonic Dextrose Solutions
Isotonic solutions that contain 5% dextrose (e.g., D5NSS, D5LRS) are slightly
hypertonic since they exceed the total osmolality of the ECF. However, dextrose is
quickly metabolized and only the isotonic solution remains. Therefore, any effect
on the ICF is temporary. Hypertonic dextrose solutions are used to provide
kilocalories for the patient in the short term. Higher concentrations of dextrose
(i.e., D50W) are strong hypertonic solutions and must be administered into
central veins so that they can be diluted by rapid blood flow.
Dextrose 10% in Water (D10W)
Dextrose 10% in Water (D10W) is an hypertonic IV solution used in the
treatment of ketosis of starvation and provides calories (380 kcal/L), free water,
and no electrolytes. It should be administered using a central line if possible and
should not be infused using the same line as blood products as it can cause RBC
hemolysis.
Dextrose 20% in Water (D20W)
Dextrose 20% in Water (D20W) is hypertonic IV solution an osmotic diuretic
that causes fluid shifts between various compartments to promote diuresis.
Dextrose 50% in Water (D50W)
Another hypertonic IV solution used commonly is Dextrose 50% in Water
(D50W) which is used to treat severe hypoglycemia and is administered rapidly
via IV bolus.
Nursing Considerations for Hypertonic IV Fluids
The following are the general nursing interventions and considerations when
administering hypertonic IV solutions:
• Document baseline data. Before infusion, assess the patient’s vital
signs, edema status, lung sounds, and heart sounds. Continue
monitoring during and after the infusion.
• Watch for signs of hypervolemia. Since hypertonic solutions move
fluid from the ICF to the ECF, they increase the extracellular fluid
volume and increases the risk for hypervolemia. Look for signs of
swelling in arms, legs, face, shortness of breath, high blood pressure,
and discomfort in the body (e.g., headache, cramping).
• Monitor and observe the patient during
administration. Hypertonic solutions should be administered only in
high acuity areas with constant nursing surveillance for potential
complications.
• Verify order. Prescription for hypertonic solutions should state the
specific hypertonic fluid to be infused, the total volume to be
infused, the infusion rate and the length of time to continue the
infusion.
• Assess health history. Patients with kidney or heart disease and
those who are dehydrated should not receive hypertonic IV fluids.
These solutions can affect renal filtration mechanisms and can easily
cause hypervolemia to patients with renal or heart problems.
• Prevent fluid overload. Ensure that administration of hypertonic
fluids does not precipitate fluid volume excess or overload.
• Do not administer peripherally. Hypertonic solutions can cause
irritation and damage to the blood vessel and should be
administered through a central vascular access device inserted into a
central vein.
• Monitor blood glucose closely. Rapid infusion of hypertonic
dextrose solutions can cause hyperglycemia. Use with caution for
patients with diabetes mellitus.
Colloids
Colloids contain large molecules that do not pass through semipermeable
membranes. Colloids are IV fluids that contain solutes of high molecular weight,
technically, they are hypertonic solutions, which when infused, exert an osmotic
pull of fluids from interstitial and extracellular spaces. They are useful for
expanding the intravascular volume and raising blood pressure. Colloids are
indicated for patients in malnourished states and patients who cannot tolerate
large infusions of fluid.
Colloid IV Fluids
and Solutions Cheat Sheet
Human Albumin
Human albumin is a solution derived from plasma. It has two strengths: 5%
albumin and 25% albumin. 5% Albumin is a solution derived from plasma and is
a commonly utilized colloid solution. It is used to increase the circulating volume
and restore protein levels in conditions such as burns, pancreatitis, and plasma
loss through trauma. 25% Albumin is used together with sodium and water
restriction to reduce excessive edema. They are considered blood transfusion
products and uses the same protocols and nursing precautions when
administering albumin.
The use of albumin is contraindicated in patients with the following conditions:
severe anemia, heart failure, or known sensitivity to albumin. Additionally,
angiotensin-converting enzyme inhibitors should be withheld for at least 24
hours before administering albumin because of the risk of atypical reactions, such
as hypotension and flushing.
Dextrans
Dextrans are polysaccharides that act as colloids. They are available in two types:
low-molecular-weight dextrans (LMWD) and high-molecular-weight dextrans
(HMWD). They are available in either saline or glucose solutions. Dextran
interferes with blood crossmatching, so draw the patient’s blood before
administering dextran, if crossmatching is anticipated.
Low-molecular-weight Dextrans (LMWD)
LMWD contains polysaccharide molecules that behave like colloids with an
average molecular weight of 40,000 (Dextran 40). LMWD is used to improve the
microcirculation in patients with poor peripheral circulation. They contain no
electrolytes and are used to treat shock related to vascular volume loss (e.g.,
burns, hemorrhage, trauma, or surgery). On certain surgical procedures, LMWDs
are used to prevent venous thromboembolism. They are contraindicated in
patients with thrombocytopenia, hypofibrinogenemia, and hypersensitivity to
dextran.
High-molecular-weight Dextrans (HMWD)
HMWD contains polysaccharide molecules with an average molecular weight of
70,000 (Dextran 70) or 75,000 (Dextran 75). HMWD used for patients with
hypovolemia and hypotension. They are contraindicated in patients with
hemorrhagic shock.
Etherified Starch
These solutions are derived from starch and are used to increase intravascular
fluid but can interfere with normal coagulation. Examples include EloHAES,
HyperHAES, and Voluven.
Gelatin
Gelatins have lower molecular weight than dextrans and therefore remain in the
circulation for a shorter period of time.
Plasma Protein Fraction (PPF)
Plasma Protein Fraction is a solution that is also prepared from plasma, and like
albumin, is heated before infusion. It is recommended to infuse slowly to increase
circulating volume.
Nursing Considerations for Colloid IV Solutions
The following are the general nursing interventions and considerations when
administering colloid IV solutions:
• Assess allergy history. Most colloids can cause allergic reactions,
although rare, so take a careful allergy history, asking specifically if
they’ve ever had a reaction to an IV infusion before.
• Use a large-bore needle (18-gauge). A larger needle is needed
when administering colloid solutions.
• Document baseline data. Before infusion, assess the patient’s vital
signs, edema status, lung sounds, and heart sounds. Continue
monitoring during and after the infusion.
• Monitor the patient’s response. Monitor intake and output closely
for signs of hypervolemia, hypertension, dyspnea, crackles in
the lungs, and edema.
• Monitor coagulation indexes. Colloid solutions can interfere with
platelet function and increase bleeding times, so monitor the
patient’s coagulation indexes.
