INTRODUCTION

The human body maintains a delicate balance of fluids

and electrolytes to help ensure proper functioning and
homeostasis. When fluids or electrolytes become
imbalanced, individuals are at risk for organ system
dysfunction. If an imbalance goes undetected and is
left untreated, organ systems cannot function properly
and ultimately death will occur. Nurses must be able to
recognize subtle changes in fluid or electrolyte
balances in their patients so they can intervene
promptly. Timely assessment and intervention prevent
complications and save lives.
 INTRODUCTION
Before learning about how to care for patients with fluid and
electrolyte imbalances, it is important to understand the physiological
processes of the body’s regulatory mechanisms. The body is in a
constant state of change as fluids and electrolytes are shifted in and
out of cells within the body in an attempt to maintain a nearly perfect
balance. A slight change in either direction can have significant
consequences on various body systems.
 GLOSSARY
Acidosis: an acid–base imbalance characterized by an increase in H+
concentration (decreased blood pH) (A low arterial pH due to reduced
bicarbonate concentration is called metabolic acidosis; a low arterial
pH due to increased PCO2 is called respiratory acidosis.)

Ascites: a type of edema in which fluid accumulates in the peritoneal

cavity

Active transport: physiologic pump that moves fluid from an area of

lower concentration to one of higher concentration; active transport
requires adenosine triphosphate for energy
 GLOSSARY
Alkalosis: an acid–base imbalance characterized by a reduction in H+
concentration (increased blood pH) (A high arterial pH with increased
bicarbonate concentration is called metabolic alkalosis; a high arterial
pH due to reduced PCO2 is called respiratory alkalosis.)

Diffusion: the process by which solutes move from an area of higher

concentration to one of lower concentration; does not require
expenditure of energy.

Homeostasis: maintenance of a constant internal equilibrium in a

biologic system that involves positive and negative feedback
mechanisms.
 GLOSSARY
Hydrostatic pressure: the pressure created by the weight of fluid
against the wall that contains it. In the body, hydrostatic pressure in
blood vessels results from the weight of fluid itself and the force
resulting from cardiac contraction.

Hypertonic solution: a solution with an osmolality higher than that of

serum

Hypotonic solution: a solution with an osmolality lower than that of

serum

Isotonic solution: a solution with the same osmolality as serum and

other body fluids
 GLOSSARY
Osmolality: the number of milliosmoles (the standard unit of osmotic
pressure) per kilogram of solvent; expressed as milliosmoles per
kilogram (mOsm/kg). (The term osmolality is used more often than
osmolarity to evaluate serum and urine.)

Osmolarity: the number of milliosmoles (the standard unit of osmotic

pressure) per liter of solution; expressed as milliosmoles per liter
(mOsm/L); describes the concentration of solutes or dissolved
particles.
 GLOSSARY
Osmosis: the process by which fluid moves across a semipermeable
membrane from an area of low solute concentration to an area of high
solute concentration; the process continues until the solute
concentrations are equal on both sides of the membrane

Tonicity: fluid tension or the effect that osmotic pressure of a solution

with impermeable solutes exerts on cell size because of water
movement across the cell membrane.
 Fundamental Concepts
Nurses need to understand the physiology of fluid and
electrolyte balance and acid–base balance to anticipate,
identify, and respond to possible imbalances. Nurses use
effective education and communication skills to help
prevent and treat various fluid and electrolyte
disturbances.
 Fundamental Concepts
Basic concepts of chemistry are involved in the
fluid and electrolyte balance and imbalance. A
solution is a mixture of solvent, which is a fluid
medium, and solutes, which are particles. Blood
is composed of blood cells that are suspended
in plasma. The blood cells include erythrocytes,
leukocytes, and platelets. Plasma composed of
92% water, which is a solvent that contains
solutes including proteins, (mainly albumin),
glucose, lipoproteins, and mineral ions, term
Fluid and Electrolyte Balance
 Necessary for life, homeostasis (maintenance of a
constant internal equilibrium in a biologic system that
involves positive and negative feedback mechanisms.)
 Nursing role: help prevent; treat fluid, electrolyte
disturbances
 Nurses need to understand the physiology of fluid and
electrolyte balance and acid–base balance to anticipate,
identify, and respond to possible imbalances.
 Nurses use effective education and communication skills
to help prevent and treat various fluid and electrolyte
disturbances.
Amount and Composition of Body Fluids
 Approximately 60% of a typical adult’s weight consists
of fluid (water and electrolytes).
 Factors that influence the amount of body fluid are age,
gender, and body fat.
 Younger people have a higher percentage of body fluid
than older adults, and men have proportionately more
body fluid than women. People who are obese have less
fluid than those who are thin,
 Muscle, skin, and blood contain the highest amounts of
water
 Amount and Composition of Body Fluids
 Body fluid is located in two fluid compartments:
- the intracellular space (fluid in the cells)
- the extracellular space (fluid outside the cells).
 Approximately two thirds of body fluid is in the
intracellular fluid (ICF) compartment and is located
primarily in the skeletal muscle mass.
 Approximately one third is in the extracellular fluid
(ECF) compartment
 Amount and Composition of Body Fluids
The Extra Cellular Fluid (ECF) compartment is further divided into
A. The intravascular space (the fluid within the blood vessels)
contains plasma, the effective circulating volume. Approximately
3 L of the average 6 L of blood volume in adults is made up of
plasma. The remaining 3 L is made up of erythrocytes,
leukocytes, and thrombocytes.
B. The interstitial space contains the fluid that surrounds the cell and
totals about 11 to 12 L in an adult. Lymph is an interstitial fluid.
C. The transcellular space is the smallest division of the ECF
compartment and contains approximately 1 L. Examples of
transcellular fluids include cerebrospinal, pericardial, synovial,
intraocular, and pleural fluids, sweat, and digestive secretions .
Amount and Composition of Body Fluids
 Electrolytes
 Active chemicals that carry positive (cations), negative
(anions) electrical charges.
Major cations: sodium, potassium, calcium, magnesium,
hydrogen ions.
Major anions: chloride, bicarbonate, phosphate, sulfate,
proteinate ions.
 Help our body regulate chemical reactions, maintain the
balance between fluids inside and outside cells, and
more.
 Electrolyte concentrations differ in fluid compartments.
 Regulation of Fluid
 Movement of fluid through capillary walls depends on
- Hydrostatic pressure: exerted on walls of blood vessels
- Osmotic pressure: exerted by protein in plasma

 Direction of fluid movement depends on differences of

hydrostatic, osmotic pressure
 Regulation of Fluid
Osmosis: area of low solute concentration to area of high
solute concentration
Diffusion: solutes move from area of higher concentration
to one of lower concentration
Filtration: movement of water, solutes occurs from area of
high hydrostatic pressure to area of low hydrostatic pressure

Active transport: physiologic pump that moves fluid from

area of lower concentration of one of higher concentration
Regulation of Fluid
 Active Transport
 Physiologic pump that moves fluid from area of lower
concentration to one of higher concentration
 Movement against concentration gradient
 Sodium–potassium pump: maintains higher concentration
of extracellular sodium, intracellular potassium
 Requires adenosine (ATP) for energy - ATP can be used
to store energy for future reactions or be withdrawn to
pay for reactions when energy is required by the cell.
 Routes of Gains and Losses
Gain
Dietary intake of fluid, food or enteral feeding
Parenteral fluids.

Loss
Kidney: urine output
Skin loss: sensible, insensible losses
Lungs
GI tract
Other
Routes of Gains and Losses (cont’d)
 Gerontologic Considerations
 Reduced homeostatic mechanisms: cardiac, renal, respiratory
function
 Decreased body fluid percentage
 Medication use
 Presence of concomitant conditions
END FOR TODAY

Week 5

Week 6 Quiz
 Fluid Volume Imbalances
 Fluid volume deficit (FVD): hypovolemia
 Fluid volume excess (FVE): hypervolemia
Fluid Volume Deficit (FVD) (Hypovolemia )

 Loss of extracellular fluid exceeds intake ratio of water

 Electrolytes lost in same proportion as they exist in normal
body fluids thus the ratio of serum electrolytes to water
remains the same.
 FVD should not be confused with Dehydration which refers
loss of water alone with increased serum sodium levels.
 FVD may occur in combination with other imbalances
Fluid Volume Deficit (Hypovolemia (cont’d)
 Dehydration

Causes: fluid loss from vomiting,

diarrhea, GI suctioning, sweating, Third-spacing occurs when
too much fluid moves from
decreased intake, inability to gain access the intravascular space (blood
to fluid vessels) into the interstitial or
“third” space—the non
functional area between cells.
Risk factors: diabetes insipidus (a This can cause potentially
decreased ability to concentrate urine due serious problems such as
to either antidiuretic hormone (ADH) or edema, reduced cardiac
output, and hypotension.
nephron resistance to ADH), adrenal
insufficiency, osmotic diuresis,
hemorrhage, coma, third-space shifts
Fluid Volume Deficit (Hypovolemia (cont’d)
Manifestations: rapid weight loss, decreased skin turgor, oliguria,
concentrated urine, postural hypotension, rapid weak pulse, increased
temperature, cool clammy skin due to vasoconstriction, lassitude,
thirst, nausea, muscle weakness, cramps.
Laboratory data:
A. Elevated BUN in relation to serum creatinine concentration
(Normal BUN to serum creatinine conc ratio is 10:1)
B. Increased hematocrit level due to decreased plasma volume which
concentrates the volume of RBC’s.
C. Serum electrolyte changes may occur (decrease/increase Na K)

OLIGURIA – excretion of less than 400ml urine/day in adult, may or

may not present in FVD.
Fluid Volume Deficit (Hypovolemia )
(cont’d)

Medical management:
provide fluids to meet body needs
Oral fluids
IV solutions
For example pt with fever - (LR or 0.9 NaCl) – first-line choice to
treat hypotensive pt with FVD bcoz they expand plasma volume.
If normotensive, a hypotonic solution (0.45%NaCl) is used to
provide both electrolyte and water for renal excretion of
metabolic waste.
Fluid Volume Deficit (Hypovolemia ) (cont’d)
Nursing Management

I&O, daily weight, vital signs

Monitor for symptoms: skin and tongue turgor, mucosa, urine
output, mental status
Measures to minimize fluid loss
Oral care
Administration of oral fluids
Administration of parenteral fluids
Fluid Volume Excess (Hypervolemia)
Refers to an expansion of the ECF caused by abnormal retention
of water and sodium in approximately the same proportions in
which they normally exist in the ECF.
Due to fluid overload or diminished homeostatic mechanisms

Risk factors: heart failure, renal failure, cirrhosis of liver.

Contributing factors: excessive dietary sodium or sodium-

containing IV solutions in a pt with impaired regulatory
mechanisms
Fluid Volume Excess (Hypervolemia)
(cont’d)

Manifestations: edema, distended neck veins, abnormal lung

sounds (crackles due to interstitial pulmonary fluid), tachycardia,
increased blood pressure, pulse pressure and CVP, increased
weight, increased urine output, shortness of breath and wheezing.

Medical management: directed at cause (if related to excessive

administration of sodium-containing fluids, discontinuing the
infusion may be all that is needed), restriction of fluids and
sodium, administration of diuretics
Fluid Volume Excess (Hypervolemia) (cont’d)

Nursing Management
• I&O and daily weights; assess lung sounds, monitor degree of
edema (feet and ankles in ambulatory patients and the sacral
• region in patients confined to bed) other symptoms
• Monitor responses to medications—diuretics
• Promote adherence to fluid restrictions, patient teaching related to
sodium and fluid restrictions
• Monitor, avoid sources of excessive sodium, including medications

• Promote rest
• Semi-Fowler’s position for orthopnea
• Skin care, positioning/turning
 Electrolyte Imbalances
 Sodium: hyponatremia, hypernatremia
 Potassium: hypokalemia, hyperkalemia
 Calcium: hypocalcemia, hypercalcemia
 Magnesium: hypomagnesemia, hypermagnesemia
 Phosphorus: hypophosphatemia, hyperphosphatemia
 Chloride: hypochloremia, hyperchloremia
 SODIUM IMBALANCES
Sodium is the most abundant electrolyte in the ECF; its
concentration ranges from 135 to 145 mEq/L (135 to 145
mmol/L), and it is the primary determinant of ECF volume
and osmolality.
Also functions in establishing the electrochemical state
necessary for muscle contraction and the transmission of
nerve impulses (Sahay & Sahay, 2014).
Sodium has a major role in controlling water distribution
throughout the body, because it does not easily cross the
cell wall membrane and because of its abundance and high
concentration in the body.
 Hyponatremia
 Serum sodium less than 135 mEq/L
 Hyponatremia can present as an acute or chronic form.
Acute hyponatremia is commonly the result of a fluid overload in a
surgical patient.
Chronic hyponatremia is seen more frequently in patients outside
the hospital setting, has a longer duration, and has less serious
neurological sequelae/result.

Causes: adrenal insufficiency, water intoxication, The syndrome of

inappropriate secretion of antidiuretic hormone (SIADH) or losses by
vomiting, diarrhea, sweating, diuretics.

Manifestations: depend on the cause, magnitude and speed with

which deficits occurs. poor skin turgor, dry mucosa, headache,
 Hyponatremia

Features of hyponatremia associated with sodium loss and water

gain include anorexia, muscle cramps, and a feeling of exhaustion.
The severity of symptoms increases with the degree of hyponatremia
and the speed with which it develops. When the serum sodium level
decreases to less than 115 mEq/L (115 mmol/L), signs of increasing
intracranial pressure, such as lethargy, confusion, muscle twitching,
focal weakness, hemiparesis, papilledema, seizures, and death, may
occur.

Medical management: water restriction, sodium replacement

Nursing management: assessment and prevention, dietary sodium

and fluid intake, identify and monitor at-risk patients, effects of
medications (diuretics, lithium)
 Hypernatremia
 Serum sodium greater than 145 mEq/L
Causes: excess water loss, fluid deprivation in patients who
cannot respond to thirst, excess sodium administration, diabetes
insipidus, heat stroke, hypertonic IV solutions.
Manifestations: A primary characteristic of hypernatremia is THIRST;
elevated temperature; dry, swollen tongue; sticky mucosa; neurologic
symptoms; restlessness; weakness
Note: thirst may be impaired in elderly or the ill.
Medical management: hypotonic electrolyte solution (0.3%NaCl) or
an isotonic nonsaline solution (D5W)
Nursing management: assessment and prevention, assess for OTC
sources of sodium ((e.g., Alka Seltzer), offer and encourage fluids to
meet patient needs, provide sufficient water with tube feedings.
monitors the patient’s response to the fluids by reviewing serial
serum sodium levels
Sodium Imbalances
 POTASSIUM IMBALANCES
 Potassium (K+) is the major intracellular electrolyte; in fact, 98%
of the body’s potassium is inside the cells. The remaining 2% is in
the ECF and is important in neuromuscular function. Potassium
influences both skeletal and cardiac muscle activity.

 The normal serum potassium concentration ranges from 3.5 to 5

mEq/L (3.5 to 5 mmol/L)

 To maintain potassium balance, the renal system must function,

because 80% of the potassium excreted daily leaves the body by
way of the kidneys; the other 20% is lost through the bowel and in
sweat.
 Hypokalemia
 Below-normal serum potassium (<3.5 mEq/L),
 may occur with normal potassium levels with alkalosis due to shift of serum
potassium into cells
Causes: GI losses, medications, alterations of acid–base balance, The normal serum
potassium concentration ranges from 3.5 to 5 mEq/L (3.5 to 5 mmol/L), poor
dietary intake.

Manifestations: fatigue, anorexia, nausea, vomiting, dysrhythmias, muscle

weakness and cramps, paresthesias (sensation of tingling, burning, pricking or
prickling, skin-crawling, itching, “pins and needles” or numbness on or just
underneath your skin), decreased muscle strength, DTRs.)Deep tendon reflexes
syndrome)
 Hypokalemia
Medical management: increased dietary potassium, potassium replacement,
IV for severe deficit. Potassium loss must be corrected daily; administration
of 40 to 80 mEq/day of potassium is adequate in the adult if there are no
abnormal losses of potassium. Dietary intake of potassium in the average
adult is 50 to 100 mEq/day. Foods high in potassium include most fruits and
vegetables, legumes, whole grains, milk, and meat (Dudek, 2013).

Nursing management: assessment (Fatigue, anorexia, muscle weakness,

decreased bowel motility, paresthesias, and dysrhythmias are signals that
warrant assessing the serum potassium concentration) severe hypokalemia is
life-threatening, monitor ECG and ABGs, dietary potassium(include
bananas, melon, citrus fruits, fresh and frozen vegetables (avoid canned
vegetables), lean meats, milk, and whole grains (Mount, 2014c)., nursing
care related to IV potassium administration. Careful monitoring of fluid I&O
is necessary, because 40 mEq of potassium is lost for every liter of urine
output.
 Hyperkalemia

 Serum potassium greater than 5.0 mEq/L

 Less common but more dangerous because cardiac arrest is more
frequently associated with high serum potassium levels.
Causes: decreased renal excretion of potassium, rapid
administration of potassium, and movement of potassium from the
ICF compartment to the ECF compartment. Usually treatment
related, impaired renal function, hypoaldosteronism, tissue trauma,
acidosis.
Medications have been identified as a probable contributing factor
in more than 60% of hyperkalemic episodes.
 Hyperkalemia

Manifestations: cardiac conduction changes and dysrhythmias,

muscle weakness with potential respiratory impairment, paresthesias,
anxiety, GI manifestations.

Medical management: monitor ECG, limitation of dietary

potassium, For STAT Drug Therapy: IV sodium bicarbonate
(necessary in severe metabolic acidosis to alkalinize the plasma, shift
potassium into the cells, and furnish sodium to antagonize the cardiac
effects of potassium, effects begin within 30 to 60 minutes ), IV
calcium gluconate, regular insulin and hypertonic dextrose IV(causes
a temporary shift of potassium into the cells), -2 agonists (move
potassium into the cells and may be used in the absence of ischemic
cardiac disease), dialysis
 Hyperkalemia (cont’d)
Nursing management:
 assessment of serum potassium levels, mix IVs containing K+ well,
monitor medication affects, dietary potassium restriction/dietary
teaching for patients at risk
 Potassium-rich foods to be avoided include many fruits and
vegetables, legumes, whole-grain breads, lean meat, milk, eggs,
coffee, tea, and cocoa (Dudek, 2013). Conversely, foods with
minimal potassium content include butter, margarine, cranberry
juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root
beer, sugar, and honey.
 Hyperkalemia (cont’d)
Nursing management:
 Hemolysis of blood specimen or drawing of blood above IV site
may result in false laboratory result
 Salt substitutes, medications may contain potassium
 Potassium-sparing diuretics may cause elevation of potassium.
 Should not be used in patients with renal dysfunction
Potassium Imbalances
 Hypocalcemia
 Serum level less than 8.6 mg/dL.
 must be considered in conjunction with serum albumin level

Causes: hypoparathyroidism, malabsorption, pancreatitis, alkalosis,

massive transfusion of citrated blood, renal failure, medications,
other.

Manifestations: tetany, circumoral numbness, paresthesias,

hyperactive DTRs, Trousseau’s sign, Chovstek's sign, seizures,
respiratory symptoms of dyspnea and laryngospasm, abnormal
clotting, anxiety.
 Hypocalcemia (cont’d)
Medical management: IV of calcium gluconate, calcium and
vitamin D supplements; diet.

Nursing management: assessment, severe hypocalcemia is life-

threatening, weight-bearing exercises to decrease bone calcium loss,
patient teaching related to diet and medications, and nursing care
related to IV calcium administration.
 Hypercalcemia
 Serum level greater than10.2 mg/dL
Causes: malignancy and hyperparathyroidism, bone loss related to
immobility
Manifestations: muscle weakness, incoordination, anorexia,
constipation, nausea and vomiting, abdominal and bone pain,
polyuria, thirst, ECG changes, dysrhythmias
Medical management: treat underlying cause, fluids, furosemide,
phosphates, calcitonin, biphosphonates
Nursing management: assessment, hypercalcemic crisis has high
mortality, encourage ambulation, fluids of 3 to 4 L/d, provide fluids
containing sodium unless contraindicated, fiber for constipation,
ensure safety.
Calcium Imbalances
Calcium Imbalances
A. Chvostek sign : consists of twitching of muscles
enervated by the facial nerve when the region that is
about 2 cm anterior to the earlobe, just below the
zygomatic arch, is tapped.

B. Trousseau sign can be elicited by inflating a blood

pressure cuff on the upper arm to about 20 mm Hg above
systolic pressure; within 2 to 5 minutes, carpal spasm (an
adducted thumb, flexed wrist and metacarpophalangeal
joints, extended interphalangeal joints with fingers
together) will occur as ischemia of the ulnar nerve
develops.
 Hypomagnesemia
 Serum level less than 1.3 mg/dL,
 evaluate in conjunction with serum albumin

Causes: alcoholism, GI losses, enteral or parenteral feeding deficient

in magnesium, medications, rapid administration of citrated blood;
contributing causes include diabetic ketoacidosis, sepsis, burns,
hypothermia

Manifestations: neuromuscular irritability, muscle weakness,

tremors, athetoid movements, ECG changes and dysrhythmias,
alterations in mood and level of consciousness
Medical management: diet, oral magnesium, magnesium sulfate IV
Hypomagnesemia (cont’d)
Nursing management:
 assessment, ensure safety, patient teaching related to diet,
medications, alcohol use, and nursing care related to IV
magnesium sulfate
 Hypomagnesemia often accompanied by hypocalcemia
- Need to monitor, treat potential hypocalcemia
 Dysphasia common in magnesium-depleted patients
-Assess ability to swallow with water before administering food
or medications
 Hypermagnesemia
 Serum level greater than 2.3 mg/dL
Causes: renal failure, diabetic ketoacidosis, excessive administration
of magnesium.
Manifestations: flushing, lowered BP, nausea, vomiting, hypoactive
reflexes, drowsiness, muscle weakness, depressed respirations, ECG
changes, dysrhythmias.
Medical management: IV calcium gluconate, loop diuretics, IV NS
of RL, hemodialysis.
Nursing management: assessment, do not administer medications
containing magnesium, patient teaching regarding magnesium-
containing OTC medications
Magnesium Imbalances
 Hypophosphatemia
 Serum level below 2.5 mg/DL
Causes: alcoholism, refeeding of patients after starvation, pain, heat stroke,
respiratory alkalosis, hyperventilation, diabetic ketoacidosis, hepatic
encephalopathy, major burns, hyperparathyroidism, low magnesium, low
potassium, diarrhea, vitamin D deficiency, use of diuretic and antacids.

Manifestations: neurologic symptoms, confusion, muscle weakness, tissue

hypoxia, muscle and bone pain, increased susceptibility to infection.

Medical management: oral or IV phosphorus replacement

Nursing management: assessment, encourage foods high in phosphorus, gradually
introduce calories for malnourished patients receiving parenteral nutrition
 Hyperphosphatemia
 Serum level above 4.5 mg/DL.

Causes: renal failure, excess phosphorus, excess vitamin D, acidosis,

hypoparathyroidism, chemotherapy.

Manifestations: few symptoms; soft-tissue calcifications, symptoms occur due to

associated hypocalcemia.

Medical management: treat underlying disorder, vitamin-D preparations, calcium-

binding antacids, phosphate-binding gels or antacids, loop diuretics, NS IV, dialysis
Nursing management: assessment, avoid high-phosphorus foods; patient teaching
related to diet, phosphate-containing substances, signs of hypocalcemia
Phosphorus Imbalances
Hypochloremia
 Serum level less than 97 mEq/L.

Causes: Addison’s disease, reduced chloride intake, GI loss, diabetic ketoacidosis,

excessive sweating, fever, burns, medications, metabolic alkalosis
Loss of chloride occurs with loss of other electrolytes, potassium, sodium

Manifestations: agitation, irritability, weakness, hyperexcitability of muscles,

dysrhythmias, seizures, coma

Medical management: replace chloride-IV NS or 0.45% NS

Nursing management: assessment, avoid free water, encourage high-chloride foods,
patient teaching related to high-chloride foods
 Hyperchloremia
 Serum level more than 107 mEq/L.

Causes: excess sodium chloride infusions with water loss, head injury,
hypernatremia, dehydration, severe diarrhea, respiratory alkalosis, metabolic
acidosis, hyperparathyroidism, medications.

Manifestations: tachypnea, lethargy, weakness, rapid, deep respirations,

hypertension, cognitive changes . Normal serum anion gap.

Medical management: restore electrolyte and fluid balance, LR, sodium

bicarbonate, diuretics

Nursing management: assessment, patient teaching related to diet and hydration

Chloride Imbalances
END FOR TODAY

Week 7
 Maintaining Acid–Base Balance

 Normal plasma pH 7.35 to 7.45: hydrogen ion concentration.

 Major extracellular fluid buffer system; bicarbonate–carbonic acid

buffer system.

 Kidneys regulate bicarbonate in ECF

 Lungs under control of medulla regulate CO2, carbonic acid in

ECF
 Maintaining Acid–Base Balance
(cont’d)
 Other buffer systems
 ECF: inorganic phosphates, plasma proteins
 ICF: proteins, organic, inorganic phosphates
 Hemoglobin
Metabolic Acidosis
 Low pH <7.35
 Low bicarbonate <22 mEq/L
 Most commonly due to renal failure
 Manifestations: headache, confusion, drowsiness, increased
respiratory rate and depth, decreased blood pressure, decreased
cardiac output, dysrhythmias, shock; if decrease is slow, patient
may be asymptomatic until bicarbonate is 15 mEq/L or less
 Correct underlying problem, correct imbalance Bicarbonate may be
administered
Metabolic Acidosis (cont’d)

 With acidosis, hyperkalemia may occur as potassium shifts out of

cell
 As acidosis is corrected, potassium shifts back into cell, potassium
levels decrease
 Monitor potassium levels
 Serum calcium levels may be low with chronic metabolic acidosis
 Must be corrected before treating acidosis
 Metabolic Alkalosis
 High pH >7.45

 High bicarbonate >26 mEq/L

 Most commonly due to vomiting or gastric suction

- May also be due to medications, especially long-term diuretic
use
 Hypokalemia will produce alkalosis

 Manifestations: symptoms related to decreased calcium,

respiratory depression, tachycardia, symptoms of hypokalemia
 Metabolic Alkalosis (cont’d)

 Correct underlying disorder, supply chloride to allow

excretion of excess bicarbonate, restore fluid volume
with sodium chloride solutions
 Respiratory Acidosis
 Low pH <7.35

 PaCO2 >42 mm Hg

 Always due to respiratory problem with inadequate excretion of

CO2

 With chronic respiratory acidosis, body may compensate, may be

asymptomatic

 Symptoms may be suddenly increased pulse, respiratory rate and

BP, mental changes, feeling of fullness in head
Respiratory Acidosis (cont’d)
 Potential increased intracranial pressure

 Treatment aimed at improving ventilation

Respiratory Alkalosis
 High pH >7.45

 PaCO2 <35 mm Hg

 Always due to hyperventilation

 Manifestations: lightheadedness, inability to concentrate,

numbness and tingling, sometimes loss of consciousness

 Correct cause of hyperventilation

Arterial Blood Gases
 pH 7.35––7.45

 PaCO2 35––45 mm Hg

 HCO3- 22–26 mEq/L

-Assumed average values for ABG interpretation
 PaO2 80–100 mm Hg

 Oxygen saturation >94%

 Base excess/deficit ±2 mEq/L

Normal Values for Arterial and Mixed Venous Bloods
PARENTERAL FLUID THERAPY

Purpose

 Generally, IV fluids are given to achieve one or more of the

following goals:

 To provide water, electrolytes, and nutrients to meet daily

requirements
 To replace water and correct electrolyte deficits
 To administer medications and blood products
Selected Water and Electrolyte Solutions
Isotonic Solutions
 are IV fluids that have a similar concentration of dissolved particles as blood.

 An example of an isotonic IV solution is 0.9% Normal Saline (0.9% NaCl).

Because the concentration of the IV fluid is similar to the blood, the fluid stays
in the intravascular space and osmosis does not cause fluid movement between
compartments.

 Isotonic solutions are used for patients with fluid volume deficit (hypovolemia)
to raise their blood pressure.

 However, infusion of too much isotonic fluid can cause excessive fluid volume
(also referred to as hypervolemia).
Hypotonic Solutions
 have a lower concentration of dissolved solutes than blood.

 An example of a hypotonic IV solution is 0.45% Normal Saline (0.45% NaCl).

 When hypotonic IV solutions are infused, it results in a decreased concentration of

dissolved solutes in the blood as compared to the intracellular space.

 This imbalance causes osmotic movement of water from the intravascular compartment
into the intracellular space. For this reason, hypotonic fluids are used to treat cellular
dehydration.

 However, if too much fluid moves out of the intravascular compartment into cells,
cerebral edema can occur. It is also possible to cause worsening hypovolemia and
hypotension if too much fluid moves out of the intravascular space and into the cells.

 Therefore, patient status should be monitored carefully when hypotonic solutions are
infused.
Hypertonic Solutions
 have a higher concentration of dissolved particles than blood.

 An example of hypertonic IV solution is 3% Normal Saline (3% NaCl).

 When infused, hypertonic fluids cause an increased concentration of dissolved

solutes in the intravascular space compared to the cells.

 This causes the osmotic movement of water out of the cells and into the
intravascular space to dilute the solutes in the blood.

 When administering hypertonic fluids, it is essential to monitor for signs of

hypervolemia such as breathing difficulties and elevated blood pressure.

 Additionally, if hypertonic solutions with sodium are given, the patient’s serum
sodium level should be closely monitored.[
Selected Water and Electrolyte Solutions
Type IV Solution Uses Nursing Considerations

Fluid resuscitation for hemorrhaging,

severe vomiting, diarrhea, GI
Monitor closely for hypervolemia, especially
Isotonic 0.9% Normal Saline (0.9% NaCl) suctioning losses, wound drainage,
with heart failure or renal failure.
mild hyponatremia, or blood
transfusions.

Should not be used if serum pH is greater than

Fluid resuscitation, GI tract fluid
7.5 because it will worsen alkalosis. May
Isotonic Lactated Ringer’s Solution (LR) losses, burns, traumas, or metabolic
elevate potassium levels if used with renal
acidosis. Often used during surgery.
failure.

Should not be used for fluid resuscitation

5% Dextrose in Water (D5W) *starts because after dextrose is metabolized, it
Provides free water to help renal
as isotonic and then changes to becomes hypotonic and leaves the
Isotonic excretion of solutes, hypernatremia,
hypotonic when dextrose is intravascular space, causing brain swelling.
and some dextrose supplementation.
metabolized Used to dilute plasma electrolyte
concentrations.
 Monitor closely for hypovolemia, hypotension,
or confusion due to fluid shifting into the
Used to treat intracellular dehydration intracellular space, which can be life-
Hypotonic 0.45% Sodium Chloride (0.45% NaCl) and hypernatremia and to provide threatening. Avoid use in patients with liver
fluid for renal excretion of solutes. disease, trauma, and burns to prevent
hypovolemia from worsening. Monitor closely
for cerebral edema.

Monitor closely for hypovolemia, hypotension,

or confusion due to fluid shifting out of the
Provides free water to promote renal
intravascular space, which can be life-
excretion of solutes and treat
Hypotonic 5% Dextrose in Water (D5W) threatening. Avoid use in patients with liver
hypernatremia, as well as some
disease, trauma, and burns to prevent
dextrose supplementation.
hypovolemia from worsening. Monitor closely
for cerebral edema.

Monitor closely for hypervolemia,

hypernatremia, and associated respiratory
Used to treat severe hyponatremia distress. Do not use it with patients
Hypertonic 3% Sodium Chloride (3% NaCl)
and cerebral edema. experiencing heart failure, renal failure, or
conditions caused by cellular dehydration
because it will worsen these conditions.
 Monitor closely for hypervolemia,
hypernatremia, and associated respiratory
5% Dextrose and 0.45% Sodium Used to treat severe hyponatremia distress. Do not use it with patients
Hypertonic
Chloride (D50.45% NaCl) and cerebral edema. experiencing heart failure, renal failure, or
conditions caused by cellular dehydration
because it will worsen these conditions.

Monitor closely for hypervolemia,

hypernatremia, and associated respiratory
5% Dextrose and Lactated Ringer’s
Used to treat severe hyponatremia distress. Do not use it with patients
Hypertonic (D5LR)
and cerebral edema. experiencing heart failure, renal failure, or
conditions caused by cellular dehydration
D10 because it will worsen these conditions.
Review IV Computations
Complications of IV Therapy
 Systematic Complication :
 Fluid overload
 Air embolism
 Septicemia, other infections

 Local Complication
 Infiltration, extravasation
 Phlebitis
 Thrombophlebitis
 Hematoma
 Clotting, obstruction
 Infiltration
• Infiltration occurs when I.V. fluid or medications leak into the surrounding
tissue.
• Infiltration can be caused by improper placement or dislodgment of the
catheter.
• Patient movement can cause the catheter to slip out or through the blood vessel
lumen.

 Signs and symptoms

 Swelling, discomfort, burning, and/or tightness
 Cool skin and blanching
 Decreased or stopped flow rate
Infiltration (cont’d)
 Prevention
 Select an appropriate I.V. site, avoiding areas of flexion.
 Use proper venipuncture technique.
 Follow your facility policy for securing the I.V. catheter.
 Observe the I.V. site frequently.
 Advise the patient to report any swelling or tenderness at the I.V. site.
Management
Stop the infusion and remove the device.
Elevate the limb to increase patient comfort; a warm compress may be applied.
Check the patient's pulse and capillary refill time.
Perform venipuncture in a different location and restart the infusion, as ordered.
Check the site frequently.
Document your findings and interventions performed.
Assessing for Infiltration
 Extravasation
 Extravasation is the leaking of vesicant drugs into surrounding tissue.
 Extravasation can cause severe local tissue damage, possibly leading to delayed
healing, infection, tissue necrosis, disfigurement, loss of function, and even
amputation.
 Signs and symptoms
 Blanching, burning, or discomfort at the I.V. site
 Cool skin around the I.V. site
 Swelling at or above the I.V. site
 Blistering and/or skin sloughing
Extravasation

 Prevention
 Avoid veins that are small and/or fragile, veins in areas of flexion, veins in
extremities with preexisting edema, or veins in areas with known neurologic
impairment.
 Be aware of vesicant medications, such as certain antineoplastic drugs
(doxorubicin, vinblastine, and vincristine), and hydroxyzine, promethazine,
digoxin, and dopamine.
 Follow your facility policy regarding vesicant administration via a peripheral
I.V.; some institutions require that vesicants are administered via a central
venous access device only.
 Give vesicants last when multiple drugs are ordered.
 Strictly adhere to proper administration techniques.
Extravasation (cont’d)

 Management
 Stop the I.V. flow and remove the I.V. line, unless the catheter should remain in
place to administer the antidote.
 Estimate the amount of extravasated solution and notify the prescriber.
 Administer the appropriate antidote according to your facility's protocol.
 Elevate the extremity.
 Perform frequent assessments of sensation, motor function, and circulation of the affected
extremity.
 Record the extravasation site, your patient's symptoms, the estimated amount of
 extravasated solution, and the treatment.
 Follow the manufacturer's recommendations to apply either cold or warm compresses to
the affected area.
 Phlebitis
Phlebitis: is inflammation of a vein. It is usually associated with
acidic or alkaline solutions or solutions that have a high osmolarity.
Phlebitis can also occur as a result of vein trauma during insertion,
use of an inappropriate I.V. catheter size for the vein, or prolonged
use of the same I.V. site.

 Signs and symptoms

•Redness or tenderness at the site of the tip of the catheter or along
the path of the vein
•Puffy area over the vein
•Warmth around the insertion site
Phlebitis (cont’d)

 Prevention
 Use proper venipuncture technique.
 Use a trusted drug reference or consult with the pharmacist for
instructions on drug dilution, when necessary.
 Monitor administration rates and inspect the I.V. site frequently.
 Change the infusion site according to your facility's policy.

 Management
 Stop the infusion at the first sign of redness or pain.
 Apply warm, moist compresses to the area.
 Document your patient's condition and interventions.
 If indicated, insert a new catheter at a different site, preferably on the
opposite arm, using a larger vein or a smaller device and restart the
infusion.
Assessing for Phlebitis
 Thrombophlebitis

 Thrombophlebitis refers to the presence of a clot plus inflammation in the

vein.
 Signs and symptoms
 localized pain, redness, warmth, and swelling
around the insertion site or along the path of the vein,
 immobility of the extremity because of discomfort and swelling, sluggish flow
rate, fever, malaise, and leukocytosis.
 Thrombophlebitis can be prevented by
 avoiding trauma to the vein at the time the IV line is inserted,
 observing the site every hour, checking
 medication additives for compatibility
Thrombophlebitis (cont’d)

 Management
 discontinuing the IV infusion;
 applying a cold compress first to decrease the flow of blood and increase platelet
aggregation, followed by a warm compress.
 elevating the extremity; and restarting the line in the opposite extremity.
 If the patient has signs and symptoms of thrombophlebitis, the IV line should not be
flushed (although flushing may be indicated in the absence of phlebitis to ensure cannula
 patency and to prevent mixing of incompatible medications and solutions).
 The catheter should be cultured after the skin around the catheter is
 cleaned with alcohol.
 If purulent drainage exists, the site is cultured before the skin is cleaned.

.
 Hematoma

Hematoma results when blood leaks into tissues surrounding the IV

insertion site. Leakage can result if the opposite vein wall is perforated
during venipuncture, the needle slips out of the vein, a cannula is too large
for the vessel, or insufficient pressure is applied to the site after removal of
the needle or cannula.
 Sign & Symptoms
ecchymosis, immediate swelling at the site, and leakage of blood at the insertion
site.
 A hematoma can be prevented by
carefully inserting the needle and by using diligent care with patients who have a
bleeding disorder, are taking anticoagulant medication, or have advanced liver
disease
Hematoma (cont’d)

 Management
 removing the needle or cannula .
 applying light pressure with a sterile, dry dressing.
 applying ice for 24 hours to the site to avoid extension of the hematoma.
 elevating the extremity to maximize venous return, if tolerated.
 assessing the extremity for any circulatory, neurologic, or motor dysfunction.
 and restarting the line in the other extremity if indicated .
 Clotting and Obstruction
Blood clots may form in the IV line as a result of kinked IV tubing, a very
slow infusion rate, an empty IV bag, or failure to flush the IV line after
intermittent medication or solution administrations.

 Sign & symptoms

decreased flow rate and blood backflow into the IV tubing.

 Management
If blood clots in the IV line, the infusion must be discontinued and
restarted in another site with a new cannula and administration set.
The tubing should not be irrigated or milked.
Neither the infusion rate nor thesolution container should be raised,
and the clot should not be aspirated from the tubing.
Clotting and Obstruction (cont’d)

 Clotting of the needle or cannula may be prevented by not

 allowing the IV solution bag to run dry.
 taping the tubing to prevent kinking and maintain patency,
 maintaining an adequate flow rate.
 flushing the line after intermittent medication or other solution
 administration.
 In some cases, a specially trained nurse or physician may inject a thrombolytic
agent into the catheter to clear an occlusion resulting from fibrin or clotted blood
 Infection
Local or systemic infection is another potential complication of I.V. therapy.

 Signs and symptoms

 Redness and discharge at the I.V. site
 Elevated temperature
 Prevention
 Perform hand hygiene, don gloves, and use aseptic technique during I.V.
insertion.
 Clean the site with approved skin antiseptic before inserting I.V. catheter.
 Ensure careful hand hygiene before any contact with the infusion system or the
patient.
 Clean injection ports before each use.
 Follow your institution’s policy for dressing changes and changing of the
solution and administration set.
Infection (cont’d)

 Management
 Stop the infusion and notify the prescriber.
 Remove the device, and culture the site and catheter as ordered.
 Administer medications as prescribed.
 Monitor the patient's vital signs.
 With careful attention and skill, you’ll be able to recognize,
prevent, and manage these complications of peripheral I.V. therapy.
 Fluid Overload.
Fluid overload is a state of increased blood volume.
Causes of Fluid overload, too much fluid is infused.

 Signs and symptoms

 Rise in blood pressure.
 Dilation of veins with neck veins sometimes visibly engorged.
 Rapid pulse, rapid breathing, shortness of breath, and rales.
 NOTE: Rales is an abnormal crackling or rattling sound heard upon listening to
sound within the chest.
 Wide variance between fluid input and urine output.
 Fluid Overload (cont’d)

 Management
 Slow the infusion to keep open rate.
 Raise the head of the patient’s bed to assist with respiratory effort.
 Immediately notify your supervisor.

 Prevention
 Monitor the urine output for all IV patients.
 Check the flow rate at frequent intervals to ensure the desired rate is being
maintained.
 Air Embolism
 Air embolism is an obstruction of a blood vessel by air carried via the
bloodstream.
 Causes
 Allowing the solution to run dry.
 Air bubbles in the IV tubing.
 Disconnected tubing.
 Signs and symptoms
 Abrupt drop in blood pressure.
 Chest pain.
 Weak, rapid pulse.
 Cyanosis (a blue-gray discoloration of the skin due to inadequate perfusion of
oxygen).
 Loss of consciousness.
Air Embolism(cont’d)

 Management
 Notify supervisor immediately.
 Administer oxygen, if allowed.
 Turn the patient on his left side and lower the head of the bed so the air bubbles
can float to and remain in the right atrium.
 The risk of serious effects of an air embolism increases if the embolism passes
to the left side of the heart.
 Prevention
 Clear all air from the tubing before attaching it to the patient.
 Monitor solutions closely and change the before they are empty.
 Check to see that all connections are secure.
References

 Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s textbook of

medical-surgical nursing. Philadelphia: Wolters Kluwer .