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Fluid, CHAPTER
Electrolyte,
and
AcidBase
52
Balance
LEARNING OUTCOMES
After completing this chapter, you will be able to:
1. Discuss the function, distribution, movement, and regu-
lation of fluids and electrolytes in the body.
2. Describe the regulation of acidbase balance in the
body, including the roles of the lungs, the kidneys and
buffers.
3. Identify factors affecting normal body fluid, electrolyte,
and acidbase balance.
4. Discuss the risk factors for and the causes and effects of
fluid, electrolyte, and acidbase imbalances.
5. Collect assessment data related to the clients fluid,
electrolyte, and acidbase balances.
6. Identify examples of nursing diagnoses, outcomes, and
interventions for clients with altered fluid, electrolyte, or
acidbase balance.
7. Teach clients measures to maintain fluid and electrolyte
balance.
8. Implement measures to correct imbalances of fluids
and electrolytes or acids and bases such as enteral or
parenteral replacements and blood transfusions.
9. Evaluate the effect of nursing and collaborative inter-
ventions on the clients fluid, electrolyte, or acidbase
balance.
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KEY TERMS
CATIONS ANIONS
200 200
Na+ HCO3
Cl
150 150
Milliequivalents per Liter (mEq/L)
HCO3
HCO3
HPO42
K+
100 100
Na+ Cl
Na+
Cl SO42
50 50
HPO42
Proteins
Org. acid
HPO42
K+ Mg2+
Proteins SO42
Ca2+ K+
0 0
Plasma Interstitial Intracellular Plasma Interstitial Intracellular
fluid fluid fluid fluid
Figure 52-2 Electrolyte composition (cations and anions) of body fluid compartments.
Martini, Fredric H.; Halyard, Rebecca A., Fundamentals of Anatomy and Physiology Interactive, (Media Edition), 4th ed., 1998. Reproduced with permission of Pearson
Education, Inc., Upper Saddle River, New Jersey.
Osmosis H20
Osmosis is the movement of water across cell membranes,
from the less concentrated solution to the more concentrated
solution (Figure 52-3 ). In other words, water moves toward H20
the higher concentration of solute in an attempt to equalize
the concentrations. H20
Solutes are substances dissolved in a liquid. For example,
when sugar is added to coffee, the sugar is the solute. Solutes
may be crystalloids (salts that dissolve readily into true solu- Dissolved Semipermeable Water
tions) or colloids (substances such as large protein molecules substances membrane molecules
that do not readily dissolve into true solutions). A solvent is the Figure 52-3 Osmosis: Water molecules move from the less
component of a solution that can dissolve a solute. In the previ- concentrated area to the more concentrated area in an attempt to
ous example, coffee is the solvent for the sugar. equalize the concentration of solutions on two sides of a membrane.
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in all fluid compartments. Osmosis is an important mechanism Higher concentration Lower concentration
for maintaining homeostasis and fluid balance.
The concentration of solutes in body fluids is usually ex-
pressed as the osmolality. Osmolality is determined by the total
solute concentration within a fluid compartment and is mea-
sured as parts of solute per kilogram of water.
Osmolality is reported as milliosmols per kilogram (mOsm/
kg). Sodium is by far the greatest determinant of serum osmolality,
with glucose and urea also contributing. Potassium, glucose, and
urea are the primary contributors to the osmolality of intracellular
Dissolved
fluid. The term tonicity may be used to refer to the osmolality of a Semipermeable
substance
solution. Solutions may be termed isotonic, hypertonic, or hypo- membrane
tonic. An isotonic solution has the same osmolality as body fluids. Figure 52-4 Diffusion: The movement of molecules through a
Normal saline, 0.9% sodium chloride, is an isotonic solution. Hyp- semipermeable membrane from an area of higher concentration to an
ertonic solutions have a higher osmolality than body fluids; 3% area of lower concentration.
sodium chloride is a hypertonic solution. Hypotonic solutions such
as one-half normal saline (0.45% sodium chloride), by contrast, quickly than smaller ones because they require more energy to
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have a lower osmolality than body fluids. move about. With diffusion, the molecules move from a solu-
Osmotic pressure is the power of a solution to draw water tion of higher concentration to a solution of lower concentration
across a semipermeable membrane. When two solutions of dif- (Figure 52-4 ). Increases in temperature increase the rate of
ferent solute concentrations are separated by a semipermeable motion of molecules and therefore the rate of diffusion.
membrane, the solution of higher solute concentration exerts a
higher osmotic pressure, drawing water across the membrane to Filtration
equalize the concentrations of the solutions. For example, infus-
Capillary bed
Substances can move across cell membranes from a less con- for an Adult
centrated solution to a more concentrated one by active trans-
SOURCE AMOUNT (ML)
port (Figure 52-6 ). This process differs from diffusion and
Oral fluids 1,200 to 1,500
osmosis in that metabolic energy is expended. In active trans-
Water in foods 1,000
port, a substance combines with a carrier on the outside surface
Water as by-product of 200
of the cell membrane, and they move to the inside surface of the food metabolism
cell membrane. Once inside, they separate, and the substance is Total 2,400 to 2,700
released to the inside of the cell. A specific carrier is required for
each substance, enzymes are required for active transport, and
energy is expended. Water as a by-product of food metabolism accounts for most
This process is of particular importance in maintaining the of the remaining fluid volume required. This quantity is approx-
differences in sodium and potassium ion concentrations of
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imately 200 mL per day for the average adult. See Table 521.
ECF and ICF. Under normal conditions, sodium concentra- The thirst mechanism is the primary regulator of fluid intake.
tions are higher in the extracellular fluid, and potassium con- The thirst center is located in the hypothalamus of the brain. A
centrations are higher inside the cells. To maintain these number of stimuli trigger this center, including the osmotic
proportions, the active transport mechanism (the sodium- pressure of body fluids, vascular volume, and angiotensin (a
potassium pump) is activated, moving sodium from the cells hormone released in response to decreased blood flow to the
and potassium into the cells. kidneys). For example, a long-distance runner loses significant
amounts of water through perspiration and rapid breathing dur-
Regulating Body Fluids ing a race, increasing the concentration of solutes and the os-
In a healthy person, the volumes and chemical composition of motic pressure of body fluids. This increased osmotic pressure
the fluid compartments stay within narrow safe limits. Nor- stimulates the thirst center, causing the runner to experience the
mally fluid intake and fluid loss are balanced. Illness can upset sensation of thirst and the desire to drink to replace lost fluids.
this balance so that the body has too little or too much fluid. Thirst is normally relieved immediately after drinking a
small amount of fluid, even before it is absorbed from the gas-
Fluid Intake trointestinal tract. However, this relief is only temporary, and
During periods of moderate activity at moderate temperature, the the thirst returns in about 15 minutes. The thirst is again tem-
average adult drinks about 1,500 mL per day but needs 2,500 mL porarily relieved after the ingested fluid distends the upper gas-
per day, an additional 1,000 mL. This added volume is acquired trointestinal tract. These mechanisms protect the individual
from foods and from the oxidation of these foods during metabolic from drinking too much, because it takes from 30 minutes to 1
processes. Interestingly, the water content of food is relatively hour for the fluid to be absorbed and distributed throughout the
large, contributing about 750 mL per day. The water content of body. See Figure 52-7 .
fresh vegetables is approximately 90%, of fresh fruits about 85%,
and of lean meats around 60%. Fluid Output
Fluid losses from the body counterbalance the adults 2,500-mL
average daily intake of fluid, as shown in Table 522. There are
Intracellular fluid Extracellular fluid four routes of fluid output:
Na+ Na+ Na+ 1. Urine
Na+ Na+ Na+
ATP Na+ Na+ 2. Insensible loss through the skin as perspiration and through
Na+ Na+ the lungs as water vapor in the expired air
Na+ Na+ Na+
Na+ Na+ Na+ 3. Noticeable loss through the skin
Na+ ATP Na+ Na+ Na+ 4. Loss through the intestines in feces
K+ K+ URINE. Urine formed by the kidneys and excreted from the uri-
K+ K+ ATP K+
K+ nary bladder is the major avenue of fluid output. Normal urine
K+ K+
K+ output for an adult is 1,400 to 1,500 mL per 24 hours, or at least
K+ K+ K+
ATP K+ 0.5 mL per kilogram per hour. In healthy people, urine output
K+ K+ K+
may vary noticeably from day to day. Urine volume automati-
cally increases as fluid intake increases. If fluid loss through per-
Cell membrane
spiration is large, however, urine volume decreases to maintain
Figure 52-6 An example of active transport. Energy (ATP) is used to fluid balance in the body.
move sodium molecules and potassium molecules across a
semipermeable membrane against sodiums and potassiums INSENSIBLE LOSSES. Insensible fluid loss occurs through the
concentration gradients (i.e., from areas of lesser concentration to skin and lungs. It is called insensible because it is usually not no-
areas of greater concentration). ticeable and cannot be measured. Insensible fluid loss through
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FECES. The chyme that passes from the small intestine into the
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Decreased volume large intestine contains water and electrolytes. The volume of
of extracellular fluid and Increased osmolality
chyme entering the large intestine in an adult is normally about
of extracellular fluid
1,500 mL per day. Of this amount, all but about 100 mL is reab-
sorbed in the proximal half of the large intestine.
Certain fluid losses are required to maintain normal body
Decreased saliva secretion function. These are known as obligatory losses. Approximately
Stimulates osmoreceptors
Maintaining Homeostasis
The volume and composition of body fluids is regulated through
Sensation of thirst: several homeostatic mechanisms. A number of body systems con-
person seeks a drink tribute to this regulation, including the kidneys, the endocrine sys-
tem, the cardiovascular system, the lungs, and the gastrointestinal
system. Hormones such as antidiuretic hormone (ADH; also
Water absorbed from known as arginine vasopressin or AVP), the renin-angiotensin-
gastrointestinal tract aldosterone system, and atrial natriuretic factor are involved, as
are mechanisms to monitor and maintain vascular volume.
Decreased osmolality KIDNEYS. The kidneys are the primary regulator of body fluids
Increased volume and of extracellular fluid and electrolyte balance. They regulate the volume and osmolal-
of extracellular fluid ity of extracellular fluids by regulating water and electrolyte ex-
cretion. The kidneys adjust the reabsorption of water from
Figure 52-7 Factors stimulating water intake through the thirst
plasma filtrate and ultimately the amount excreted as urine. Al-
mechanism.
though 135 to 180 L of plasma per day is normally filtered in an
From Lemone, Priscilla; Burke, Karen M., Medical Surgical Nursing: Critical Thinking in
Client Care, 3rd ed 2004. Reproduced with permission of Pearson Education, Inc., adult, only about 1.5 L of urine is excreted. Electrolyte balance
Upper Saddle River, New Jersey. is maintained by selective retention and excretion by the kid-
the skin occurs in two ways. Water is lost through diffusion and neys. The kidneys also play a significant role in acidbase regu-
through perspiration (which is noticeable but not measurable). lation, excreting hydrogen ion (H) and retaining bicarbonate.
Water losses through diffusion are not noticeable but normally ANTIDIURETIC HORMONE. Antidiuretic hormone, which regu-
account for 300 to 400 mL per day. This loss can be significantly lates water excretion from the kidney, is synthesized in the ante-
increased if the protective layer of the skin is lost as with burns rior portion of the hypothalamus and acts on the collecting ducts
or large abrasions. Perspiration varies depending on factors such of the nephrons. When serum osmolality rises, ADH is produced,
as environmental temperature and metabolic activity. Fever and causing the collecting ducts to become more permeable to water.
exercise increase metabolic activity and heat production, thereby This increased permeability allows more water to be reabsorbed
increasing fluid losses through the skin. into the blood. As more water is reabsorbed, urine output falls
Another type of insensible loss is the water in exhaled air. In and serum osmolality decreases because the water dilutes body
an adult, this is normally 300 to 400 mL per day. When respira- fluids. Conversely, if serum osmolality decreases, ADH is sup-
tory rate accelerates, for example, due to exercise or an elevated pressed, the collecting ducts become less permeable to water,
body temperature, this loss can increase. and urine output increases. Excess water is excreted, and serum
osmolality returns to normal. Other factors also affect the pro-
TABLE 522 Average Daily Fluid Output duction and release of ADH, including blood volume, tempera-
for an Adult ture, pain, stress, and some drugs such as opiates, barbiturates,
ROUTE AMOUNT (ML) and nicotine. See Figure 52-8 .
Urine 1,400 to 1,500
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM. Specialized
Insensible losses
Lungs 350 to 400
receptors in the juxtaglomerular cells of the kidney nephrons re-
Skin 350 to 400
spond to changes in renal perfusion. This initiates the renin-
angiotensin-aldosterone system. If blood flow or pressure to the
Sweat 100
Feces 100 to 200
kidney decreases, renin is released. Renin causes the conversion
Total 2,300 to 2,600
of angiotensinogen to angiotensin I, which is then converted to
angiotensin II by angiotensin-converting enzyme. Angiotensin II
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Osmoreceptors in
hypothalamus
ADH is suppressed
stimulate posterior
pituitary to secrete ADH
Reabsorption Reabsorption
of H2O of H2O
into blood into blood
Figure 52-8 Antidiuretic hormone (ADH) regulates water excretion from the kidneys.
acts directly on the nephrons to promote sodium and water reten- maintaining electrolyte balance. Although the concentration of
tion. In addition, it stimulates the release of aldosterone from specific electrolytes differs between fluid compartments, a bal-
the adrenal cortex. Aldosterone also promotes sodium retention ance of cations (positively charged ions) and anions (negatively
in the distal nephron. The net effect of the renin-angiotensin- charged ions) always exists. Electrolytes are important for
aldosterone system is to restore blood volume (and renal perfu-
Maintaining fluid balance.
sion) through sodium and water retention.
Contributing to acidbase regulation.
ATRIAL NATRIURETIC FACTOR. Atrial natriuretic factor (ANF) Facilitating enzyme reactions.
is released from cells in the atrium of the heart in response to ex- Transmitting neuromuscular reactions.
cess blood volume and stretching of the atrial walls. Acting on Most electrolytes enter the body through dietary intake and
the nephrons, ANF promotes sodium wasting and acts as a po- are excreted in the urine. Some electrolytes, such as sodium and
tent diuretic, thus reducing vascular volume. ANF also inhibits chloride, are not stored by the body and must be consumed daily
thirst, reducing fluid intake. to maintain normal levels. Potassium and calcium, on the other
hand, are stored in the cells and bone, respectively. When serum
Regulating Electrolytes levels drop, ions can shift out of the storage pool into the
Electrolytes, charged ions capable of conducting electricity, are blood to maintain adequate serum levels for normal function-
present in all body fluids and fluid compartments. Just as main- ing. The regulatory mechanisms and functions of the major
taining the fluid balance is vital to normal body function, so is electrolytes are summarized in Table 523.
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Movement into and out of cells Regulating cardiac impulse transmission and muscle
Insulin helps move K into cells; tissue damage and contraction
acidosis shift K out of cells into ECF Skeletal and smooth muscle function
Calcium (Ca2) Redistribution between bones and ECF Forming bones and teeth
Blood clotting
phospholipase
Magnesium (Mg2) Conservation and excretion by kidneys Intracellular metabolism
Chloride (Cl) Excreted and reabsorbed along with sodium in the HCl production
Phosphate (PO4) Excretion and reabsorption by the kidneys Forming bones and teeth
Parathyroid hormone decreases serum levels by Metabolizing carbohydrate, protein, and fat
Reciprocal relationship with calcium: increasing serum Muscle, nerve, and RBC function
Bicarbonate (HCO3) Excretion and reabsorption by the kidneys Major body buffer involved in acidbase regulation
Regeneration by kidneys
ECF fall, parathyroid hormone and calcitriol cause calcium to that of a newborn nearly twice that of an adult. Higher levels of
be released from bones into ECF and increase the absorption of growth hormone and a faster rate of skeletal growth probably
calcium in the intestines, thus raising serum calcium levels. account for this difference. Phosphate is involved in many
Conversely, calcitonin stimulates the deposition of calcium in chemical actions of the cell; it is essential for functioning of
bone, reducing the concentration of calcium ions in the blood. muscles, nerves, and red blood cells. It is also involved in the
With aging, the intestines absorb calcium less effectively and metabolism of protein, fat, and carbohydrate. Phosphate is ab-
more calcium is excreted via the kidneys. Calcium shifts out of sorbed from the intestine and is found in many foods such as
the bone to replace these ECF losses, increasing the risk of os- meat, fish, poultry, milk products, and legumes.
teoporosis and fractures of the wrists, vertebrae, and hips. Lack
of weight-bearing exercise (which helps keep calcium in the Bicarbonate HCO3
bones) and a vitamin D deficiency because of inadequate expo- Bicarbonate is present in both intracellular and extracellular flu-
sure to sunlight contribute to this risk. ids. Its primary function is regulating acidbase balance as an
Milk and milk products are the richest sources of calcium, essential component of the carbonic acidbicarbonate buffering
with other foods such as dark green leafy vegetables and canned system. Extracellular bicarbonate levels are regulated by the
salmon containing smaller amounts. Many clients benefit from kidneys: Bicarbonate is excreted when too much is present; if
calcium supplements. more is needed, the kidneys both regenerate and reabsorb bicar-
Serum calcium levels are often reported in two ways, based bonate ions. Unlike other electrolytes that must be consumed in
upon the way it is circulating in the plasma. Approximately 50% the diet, adequate amounts of bicarbonate are produced through
of serum calcium circulates in a free, ionized, or unbound form. metabolic processes to meet the bodys needs.
The other 50% circulates in the plasma bound to either plasma
proteins or other nonprotein ions. The normal total serum cal- ACIDBASE BALANCE
cium levels, which range from 8.5 to 10.5 mg/dL, represent both An important part of regulating the chemical balance or home-
bound and unbound calcium. The normal ionized serum calcium, ostasis of body fluids is regulating their acidity or alkalinity. An
which ranges from 4.0 to 5.0 mg/dL, represents calcium circulat- acid is a substance that releases hydrogen ions (H) in solution.
ing in the plasma in free, or unbound, form (Hayes, 2004). Strong acids such as hydrochloric acid release all or nearly all
their hydrogen ions; weak acids like carbonic acid release some
Magnesium (Mg2)
hydrogen ions. Bases or alkalis have a low hydrogen ion con-
Magnesium is primarily found in the skeleton and in intracellu- centration and can accept hydrogen ions in solution. The rela-
lar fluid. It is the second most abundant intracellular cation with tive acidity or alkalinity of a solution is measured as pH. The pH
normal serum levels of 1.5 to 2.5 mEq/L. It is important for in- reflects the hydrogen ion concentration of the solution: The
tracellular metabolism, being particularly involved in the pro- higher the hydrogen ion concentration (and the more acidic the
duction and use of ATP. Magnesium also is necessary for protein solution), the lower the pH. Water has a pH of 7 and is neutral;
and DNA synthesis within the cells. Only about 1% of the that is, it is neither acidic in nature nor is it alkaline. Solutions
bodys magnesium is in ECF; here it is involved in regulating with a pH lower than 7 are acidic; those with a pH higher than
neuromuscular and cardiac function. Maintaining and ensuring 7 are alkaline. The pH scale is logarithmic: A solution with a pH
adequate magnesium levels is an important part of care of of 5 is 10 times more acidic than one with a pH of 6.
clients with cardiac disorders. Cereal grains, nuts, dried fruit,
legumes, and green leafy vegetables are good sources of mag- Regulation of AcidBase Balance
nesium in the diet, as are dairy products, meat, and fish. Body fluids are maintained within a narrow range that is slightly
Chloride (Cl ) alkaline. The normal pH of arterial blood is between 7.35 and
7.45 (Figure 52-9 ). Acids are continually produced during me-
Chloride is the major anion of ECF, and normal serum levels are
95 to 108 mEq/L. Chloride functions with sodium to regulate pH
serum osmolality and blood volume. The concentration of chlo-
6.8 7.35 7.45 7.8
ride in ECF is regulated secondarily to sodium; when sodium is
reabsorbed in the kidney, chloride usually follows. Chloride is a
major component of gastric juice as hydrochloric acid (HCl) Death Acidosis Normal Alkalosis Death
and is involved in regulating acidbase balance. It also acts as a
buffer in the exchange of oxygen and carbon dioxide in RBCs.
Chloride is found in the same foods as sodium. pH scale
Phosphate PO4 1
Acidic
7
Neutral
14
Alkaline
Phosphate is the major anion of intracellular fluids. It also is solution solution
found in ECF, bone, skeletal muscle, and nerve tissue. Normal (high H+) (low H+)
serum levels of phospate in adults range from 2.5 to 4.5 mg/dL. Figure 52-9 Body fluids are normally slightly alkaline, between a pH
Children have much higher phosphate levels than adults, with of 7.35 and 7.45.
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tabolism. Several body systems, including buffers, the respira- breaks down into carbon dioxide and water. Working together
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tory system, and the renal system, are actively involved in main- with the bicarbonatecarbonic acid buffer system, the lungs reg-
taining the narrow pH range necessary for optimal function. ulate acidbase balance and pH by altering the rate and depth of
Buffers help maintain acidbase balance by neutralizing excess respirations. The response of the respiratory system to changes
acids or bases. The lungs and the kidneys help maintain a nor- in pH is rapid, occurring within minutes.
mal pH by either excreting or retaining acids and bases. Carbon dioxide is a powerful stimulator of the respiratory
center. When blood levels of carbonic acid and carbon dioxide
Buffers
The lungs and kidneys are the two major systems that are working on
a continuous basis to help regulate the acidbase balance in the body.
In the biochemical reactions above, the processes are all reversible and
go back and forth as the bodys needs change. The lungs can work very
quickly and do their part by either retaining or getting rid of carbon diox-
ide by changing the rate and depth of respirations. The kidneys work
much more slowly; they may take hours to days to regulate the bal-
Death Acidosis Normal Alkalosis Death ance by either excreting or conserving hydrogen and bicarbonate ions.
6.8 7.35 7.45 7.8 Under normal conditions, the two systems work together to maintain
homeostasis.
Figure 52-10 Carbonic acidbicarbonate ratio and pH.
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FACTORS AFFECTING BODY FLUID, adult has thinner, more fragile skin and veins, which can make
an intravenous insertion more difficult.
ELECTROLYTES, AND
ACIDBASE BALANCE Gender and Body Size
The ability of the body to adjust fluids, electrolytes, and
Total body water also is affected by gender and body size. Be-
acidbase balance is influenced by age, gender and body size,
cause fat cells contain little or no water, and lean tissue has a
environmental temperature, and lifestyle.
high water content, people with a higher percentage of body fat
have less body fluid. Women have proportionately more body
Age fat and less body water than men. Water accounts for approxi-
Infants and growing children have much greater fluid turnover mately 60% of an adult mans weight, but only 52% for an adult
than adults because their higher metabolic rate increases fluid woman. In an obese individual this may be even less, with wa-
loss. Infants lose more fluid through the kidneys because imma- ter responsible for only 30% to 40% of the persons weight.
ture kidneys are less able to conserve water than adult kidneys.
In addition, infants respirations are more rapid and the body
surface area is proportionately greater than that of adults, in-
Environmental Temperature
creasing insensible fluid losses. The more rapid turnover of People with an illness and those participating in strenuous ac-
fluid plus the losses produced by disease can create critical fluid tivity are at risk for fluid and electrolyte imbalances when the
imbalances in children much more rapidly than in adults. environmental temperature is high. Fluid losses through sweat-
In elderly people, the normal aging process may affect fluid ing are increased in hot environments as the body attempts to
balance. The thirst response often is blunted. Antidiuretic hor- dissipate heat. These losses are even greater in people who have
mone levels remain normal or may even be elevated, but the not been acclimatized to the environment.
nephrons become less able to conserve water in response to Both salt and water are lost through sweating. When only
ADH. Increased levels of atrial natriuretic factor seen in older water is replaced, salt depletion is a risk. The person who is salt
adults may also contribute to this impaired ability to conserve depleted may experience fatigue, weakness, headache, and gas-
water. These normal changes of aging increase the risk of dehy- trointestinal symptoms such as anorexia and nausea. The risk of
dration. When combined with the increased likelihood of heart adverse effects is even greater if lost water is not replaced. Body
diseases, impaired renal function, and multiple drug regimens, temperature rises, and the person is at risk for heat exhaustion
the older adults risk for fluid and electrolyte imbalance is sig- or heatstroke. Heatstroke may occur in older adults or ill people
nificant. Additionally, it is important to consider that the older during prolonged periods of heat; it can also affect athletes and
laborers when their heat production exceeds the bodys ability acidbase balance. Diabetic ketoacidosis, cancer, and head in-
to dissipate heat. jury may also lead to electrolyte imbalances.
Consuming adequate amounts of cool liquids, particularly dur-
ing strenuous activity, reduces the risk of adverse effects from Fluid Imbalances
heat. Balanced electrolyte solutions and carbohydrate-electrolyte Fluid imbalances are of two basic types: isotonic and osmolar.
solutions such as sports drinks are recommended because they Isotonic imbalances occur when water and electrolytes are lost
replace both water and electrolytes lost through sweat. or gained in equal proportions, so that the osmolality of body
fluids remains constant. Osmolar imbalances involve the loss
Lifestyle or gain of only water, so that the osmolality of the serum is al-
Other factors such as diet, exercise, and stress affect fluid, elec- tered. Thus four categories of fluid imbalances may occur:
trolyte, and acidbase balance. (a) an isotonic loss of water and electrolytes, (b) an isotonic
The intake of fluids and electrolytes is affected by the diet. gain of water and electrolytes, (c) a hyperosmolar loss of only
People with anorexia nervosa or bulimia are at risk for severe water, and (d) a hypo-osmolar gain of only water. These are re-
fluid and electrolyte imbalances because of inadequate intake or ferred to, respectively, as fluid volume deficit, fluid volume
purging regimens (e.g., induced vomiting, use of diuretics and excess, dehydration (hyperosmolar imbalance), and overhy-
laxatives). Seriously malnourished people have decreased dration (hypo-osmolar imbalance).
serum albumin levels, and may develop edema because the os-
motic draw of fluid into the vascular compartment is reduced. Fluid Volume Deficit
When calorie intake is not adequate to meet the bodys needs, Isotonic fluid volume deficit (FVD) occurs when the body loses
fat stores are broken down and fatty acids are released, increas- both water and electrolytes from the ECF in similar proportions.
ing the risk of acidosis. Thus, the decreased volume of fluid remains isotonic. In FVD,
Regular weight-bearing physical exercise such as walking, fluid is initially lost from the intravascular compartment, so it
running, or bicycling has a beneficial effect on calcium balance. often is called hypovolemia.
The rate of bone loss that occurs in postmenopausal women and FVD generally occurs as a result of (a) abnormal losses
older men is slowed with regular exercise, reducing the risk of through the skin, gastrointestinal tract, or kidney; (b) de-
osteoporosis. creased intake of fluid; (c) bleeding; or (d) movement of fluid
Stress can increase cellular metabolism, blood glucose con- into a third space. See the section on third space syndrome
centration, and catecholamine levels. In addition, stress can in- that follows.
crease production of ADH, which in turn decreases urine For the risk factors and clinical signs related to fluid volume
production. The overall response of the body to stress is to in- deficit, see Table 524.
crease the blood volume. THIRD SPACE SYNDROME. In third space syndrome, fluid
Other lifestyle factors can also affect fluid, electrolyte, and shifts from the vascular space into an area where it is not readily
acidbase balance. Heavy alcohol consumption affects elec- accessible as extracellular fluid. This fluid remains in the body
trolyte balance, increasing the risk of low calcium, magnesium, but is essentially unavailable for use, causing an isotonic fluid
and phosphate levels. The risk of acidosis associated with
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volume deficit. Fluid may be sequestered in the bowel, in the in-
breakdown of fat tissue also is greater in the person who drinks terstitial space as edema, in inflamed tissue, or in potential
large amounts of alcohol. spaces such as the peritoneal or pleural cavities.
The client with third space syndrome has an isotonic fluid
DISTURBANCES IN FLUID deficit but may not manifest apparent fluid loss or weight loss.
VOLUME, ELECTROLYTE, Careful nursing assessment is vital to effectively identify and in-
AND ACIDBASE BALANCES tervene for clients experiencing third-spacing. Because the fluid
Fever
Monitor fluid intake and output.
Fluid intake less than output
Nasogastric suction Monitor laboratory findings.
Decreased tissue turgor
Abnormal drainage or wound losses Administer oral and intravenous fluids as
Dry mucous membranes, sunken eyeballs, indicated.
Insufficient intake due to decreased tearing
Anorexia Provide frequent mouth care.
Nausea
Subnormal temperature
Implement measures to prevent skin
Inability to access fluids Weak, rapid pulse breakdown.
Impaired swallowing Decreased blood pressure Provide for safety, e.g., provide assistance for
Confusion, depression Postural (orthostatic) hypotension (significant a client rising from bed.
drop in BP when moving from lying to sitting
or standing position)
Flat neck veins; decreased capillary refill
Decreased central venous pressure
Decreased urine volume (<30 mL/h)
Increased specific gravity of urine (>1.030)
Increased hematocrit
Increased blood urea nitrogen (BUN)
with impaired regulatory mechanisms; and (c) disease hydrostatic pressures, pushing fluid into the interstitial tissues.
processes that alter regulatory mechanisms, such as heart fail- This type of edema is often seen in dependent tissues such as the
ure, renal failure, cirrhosis of the liver, and Cushings syndrome. feet, ankles, and sacrum because of the effects of gravity. Low
The risk factors and clinical manifestations for FVE are sum- levels of plasma proteins from malnutrition or liver or kidney
marized in Table 525. diseases can reduce the plasma oncotic pressure so that fluid is
not drawn into the capillaries from interstitial tissues, causing
EDEMA. In fluid volume excess, both intravascular and intersti- edema. With tissue trauma and some disorders such as allergic
tial spaces have an increased water and sodium content. Excess reactions, capillaries become more permeable, allowing fluid to
interstitial fluid is known as edema. Edema typically is most ap- escape into interstitial tissues. Obstructed lymph flow impairs
parent in areas where the tissue pressure is low, such as around the movement of fluid from interstitial tissues back into the vas-
the eyes, and in dependent tissues (known as dependent edema), cular compartment, resulting in edema.
where hydrostatic capillary pressure is high. Pitting edema is edema that leaves a small depression or pit
Edema can be caused by several different mechanisms. The after finger pressure is applied to the swollen area. The pit is
three main mechanisms are increased capillary hydrostatic pres- caused by movement of fluid to adjacent tissue, away from the
sure, decreased plasma oncotic pressure, and increased capil- point of pressure (Figure 52-11 ). Within 10 to 30 seconds the
lary permeability. It may be due to FVE that increases capillary pit normally disappears.
2mm
1+ Barely detectable
4mm
2+ 2 to 4 mm
6mm
3+ 5 to 7 mm
12mm
4+ More than 7 mm
A B
Figure 52-11 Evaluation of edema. A, Palpate for edema over the tibia as shown here and behind the medial malleolus, and over the dorsum of
each foot. B, Four-point scale for grading edema.
Dehydration Overhydration
Dehydration, or hyperosmolar imbalance, occurs when water is Overhydration, also known as hypo-osmolar imbalance or water
lost from the body leaving the client with excess sodium. Be- excess, occurs when water is gained in excess of electrolytes, re-
cause water is lost while electrolytes, particularly sodium, are sulting in low serum osmolality and low serum sodium levels.
retained, the serum osmolality and serum sodium levels in- Water is drawn into the cells, causing them to swell. In the brain
crease. Water is drawn into the vascular compartment from the this can lead to cerebral edema and impaired neurologic func-
interstitial space and cells, resulting in cellular dehydration. tion. Water intoxication often occurs when both fluid and elec-
Older adults are at particular risk for dehydration because of de- trolytes are lost, for example, through excessive sweating, but
creased thirst sensation. This type of water deficit also can af- only water is replaced. It can also result from the syndrome of
fect clients who are hyperventilating or have prolonged fever or inappropriate antidiuretic hormone (SIADH), a disorder that can
are in diabetic ketoacidosis and those receiving enteral feedings occur with some malignant tumors, AIDS, head injury, or ad-
with insufficient water intake. ministration of certain drugs such as barbiturates or anesthetics.
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ment of hepatic or renal disease. Therapeutic effects include diuresis and lowering of blood pressure.
diuretic which excretes potassium and may result in than 3 lb in 1 day to your primary care provider.
hypokalemia. Contact your primary care provider immediately if you begin to
Administer in the morning to avoid increased urination during experience muscle weakness, cramps, nausea, dizziness,
hours of sleep. numbness, or tingling of the extremities.
If the client is also taking digitalis glycosides, he or she should be Some form of potassium supplementation will be needed. The
assessed for anorexia, nausea, vomiting, muscle cramps, pares- primary care provider may order oral potassium supplements for
thesia, and confusion. The potassium-depleting effect of you; if not, you will need to consume a diet high in potassium.
furosemide places the client at increased risk for digitalis toxicity. Make position changes slowly in order to minimize dizziness
from orthostatic hypotension.
Note: Prior to administering any medication, review all aspects with a current drug handbook or other reliable source.
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AIDS
Malignant tumors
Hypernatremia
Loss of water Thirst Monitor fluid intake and output.
Insensible water loss (hyperventilation Dry, sticky mucous membranes Monitor behavior changes (e.g., restlessness,
or fever) Tongue red, dry, swollen disorientation).
Diarrhea
Weakness Monitor laboratory findings (e.g., serum
Water deprivation sodium).
Gain of sodium Severe hypernatremia: Encourage fluids as ordered.
Parenteral administration of saline Fatigue, restlessness Monitor diet as ordered (e.g., restrict intake of
solutions Decreasing level of consciousness salt and foods high in sodium).
Hypertonic tube feedings without Disorientation
adequate water Convulsions
Excessive use of table salt (1 tsp
Laboratory findings:
contains 2,300 mg of sodium)
Serum sodium above 145 mEq/L
Conditions such as
Serum osmolality above 300 mOsm/kg
Diabetes insipidus
Heat stroke
Hypokalemia
Loss of potassium Muscle weakness, leg cramps Monitor heart rate and rhythm.
Vomiting and gastric suction Fatigue, lethargy Monitor clients receiving digitalis (e.g., digoxin)
Diarrhea Anorexia, nausea, vomiting closely, because hypokalemia increases risk of
Heavy perspiration
Decreased bowel sounds, decreased bowel digitalis toxicity.
Use of potassium-wasting drugs (e.g., motility Administer oral potassium as ordered with
diuretics) Cardiac dysrhythmias food or fluid to prevent gastric irritation.
Poor intake of potassium (as with
Depressed deep-tendon reflexes Administer IV potassium solutions at a rate no
debilitated clients, alcoholics, anorexia faster than 1020 mEq/h; never administer
Weak, irregular pulses undiluted potassium intravenously. For clients
nervosa)
Laboratory findings: receiving IV potassium, monitor for pain and
Hyperaldosteronism
Serum potassium below 3.5 mEq/L inflammation at the injection site.
Arterial blood gases (ABGs) may show alkalosis Teach client about potassium-rich foods.
T wave flattening and ST segment depression Teach clients how to prevent excessive loss of
on ECG potassium (e.g., through abuse of diuretics
and laxatives).
Hyperkalemia
Decreased potassium excretion Gastrointestinal hyperactivity, diarrhea Closely monitor cardiac status and ECG.
Renal failure Irritability, apathy, confusion Administer diuretics and other medications
Hypoaldosteronism
Cardiac dysrhythmias or arrest such as glucose and insulin as ordered.
Potassium-conserving diuretics
Muscle weakness, areflexia (absence of Hold potassium supplements and K
High potassium intake reflexes) conserving diuretics.
Decreased heart rate;
Irregular pulse
Hypocalcemia
Surgical removal of the parathyroid
glands Numbness, tingling of the extremities and Closely monitor respiratory and cardiovascular
Conditions such as around the mouth status.
Hypoparathyroidism Muscle tremors, cramps; if severe can progress Take precautions to protect a confused client.
Acute pancreatitis to tetany and convulsions Administer oral or parenteral calcium
Hyperphosphatemia Cardiac dysrhythmias; decreased cardiac output supplements as ordered. When administering
Thyroid carcinoma Positive Trousseaus and Chvosteks signs (see intravenously, closely monitor cardiac status
Table 528) and ECG during infusion.
Inadequate vitamin D intake
Malabsorption
Confusion, anxiety, possible psychoses Teach clients at high risk for osteoporosis about
Hyperactive deep tendon reflexes Dietary sources rich in calcium.
Hypomagnesemia
Recommendation for 1,0001,500 mg of
Alkalosis Laboratory findings:
calcium per day.
Sepsis Serum calcium less than 8.5 mg/dL or
Calcium supplements.
Alcohol abuse 4.5 mEq/L (total)
Regular exercise.
Lengthened QT intervals
Estrogen replacement therapy for
around the mouth and hands and feet) and can lead to convul-
CLINICAL ALERT sions. Two signs indicate hypocalcemia: The Chvosteks sign is
Potassium may be given intravenously for severe hypokalemia. It must contraction of the facial muscles that is produced by tapping the
ALWAYS be diluted appropriately and NEVER be given IV push. Potassium facial nerve in front of the ear (Figure 52-13 , A). Trousseaus
that is to be given IV should be mixed in the pharmacy and double- sign is a carpal spasm that occurs by inflating a blood pressure
checked prior to administration by two nurses. The usual concentration of
IV potassium is 20 to 40 mEq/L.
cuff on the upper arm to 20 mm Hg greater than the systolic
pressure for 2 to 5 minutes (Figure 52-13 , B). Clients at great-
est risk for hypocalcemia are those whose parathyroid glands
Calcium have been removed. This is frequently associated with total thy-
Regulating levels of calcium (Ca2) in the body is more com- roidectomy or bilateral neck surgery for cancer. Low serum
plex than the other major electrolytes so calcium balance can be magnesium levels (hypomagnesemia) and chronic alcoholism
affected by many factors. Imbalances of this electrolyte are rel- also increase the risk of hypocalcemia.
atively common. Hypercalcemia, or total serum calcium levels greater than
Hypocalcemia is a calcium deficit, or a total serum calcium 10.5 mg/dL, or an ionized calcium level of greater than 5.0
level of less than 8.5 mg/dL or an ionized calcium level of less mg/dL, most often occurs when calcium is mobilized from the
than 4.0 mg/dL. Severe depletion of calcium can cause tetany bony skeleton. This may be due to malignancy or prolonged im-
with muscle spasms and paresthesias (numbness and tingling mobilization.
The risk factors and clinical manifestations related to cal- serum phosphate levels may experience numbness and tingling
cium imbalances are found in Table 526. around the mouth and in the fingertips, muscle spasms, and tetany.
Magnesium
AcidBase Imbalances
Magnesium (Mg2) imbalances are relatively common in
Acidbase imbalances generally are classified as respiratory or
hospitalized clients, although they may be unrecognized.
metabolic by the general or underlying cause of the disorder. Car-
Hypomagnesemia is a magnesium deficiency, or a total serum
bonic acid levels are normally regulated by the lungs through the
magnesium level of less than 1.5 mEq/L. It occurs more fre-
retention or excretion of carbon dioxide, and problems of regula-
quently than hypermagnesemia. Chronic alcoholism is the most
tion lead to respiratory acidosis or alkalosis. Bicarbonate and hy-
common cause of hypomagnesemia. Magnesium deficiency also
drogen ion levels are regulated by the kidneys, and problems of
may aggravate the manifestations of alcohol withdrawal, such as
regulation lead to metabolic acidosis or alkalosis. Healthy regula-
delirium tremens (DTs). Hypermagnesemia is present when the
tory systems will attempt to correct acidbase imbalances, a
serum magnesium level rises above 2.5 mEq/L. It is due to in-
process called compensation.
creased intake or decreased excretion. It is often iatrogenic, that
is, a result of overzealous magnesium therapy.
Respiratory Acidosis
Table 526 lists risk factors and manifestations for clients
with altered magesium balance. Hypoventilation and carbon dioxide retention cause carbonic acid
levels to increase and the pH to fall below 7.35, a condition
Chloride known as respiratory acidosis. Serious lung diseases such as
Because of the relationship between sodium ions and chloride asthma and COPD are common causes of respiratory acidosis.
ions (Cl), imbalances of chloride commonly occur in conjunc- Central nervous system depression due to anesthesia or a narcotic
tion with sodium imbalances. Hypochloremia is a decreased overdose can sufficiently slow the respiratory rate so that carbon
serum chloride level, in adults a level below 95 mEq/L, and is dioxide is retained. When respiratory acidosis occurs, the kidneys
usually related to excess losses of chloride ion through the GI retain bicarbonate to restore the normal carbonic acid to bicarbon-
tract, kidneys, or sweating. Hypochloremic clients are at risk ate ratio. Recall, however, that the kidneys are relatively slow to
for alkalosis and may experience muscle twitching, tremors, or respond to changes in acidbase balance, so this compensatory
tetany. response may require hours to days to restore the normal pH.
Conditions that cause sodium retention also can lead to a high
Respiratory Alkalosis
serum chloride level or hyperchloremia, in adults a level above
108 mEq/L. Excess replacement of sodium chloride or potassium When a person hyperventilates, more carbon dioxide than nor-
chloride are additional risk factors for high serum chloride levels. mal is exhaled, carbonic acid levels fall, and the pH rises to
The manifestations of hyperchloremia include acidosis, weak- greater than 7.45. This condition is termed respiratory alkalosis.
ness, and lethargy, with a risk of dysrhythmias and coma. Psychogenic or anxiety-related hyperventilation is a common
cause of respiratory alkalosis. Other causes include fever and
Phosphate respiratory infections. In respiratory alkalosis, the kidneys will
The phosphate anion PO4 is found in both intracellular and ex- excrete bicarbonate to return the pH to within the normal range.
tracellular fluid. Most of the phosphorus (P) in the body exists Often, however, the cause of the hyperventilation is eliminated
as PO4. Phosphate is critical for cellular metabolism because it and the pH returns to normal before renal compensation occurs.
is a major component of adenosine triphosphate (ATP).
Phosphate imbalances frequently are related to therapeutic in- Metabolic Acidosis
terventions for other disorders. Glucose and insulin administra- When bicarbonate levels are low in relation to the amount of
tion and total parenteral nutrition can cause phosphate to shift carbonic acid in the body, the pH falls and metabolic acidosis
into the cells from extracellular fluid compartments, leading to develops. This may develop because of renal failure and the in-
hypophosphatemia, defined in adults as a total serum phosphate ability of the kidneys to excrete hydrogen ion and produce bi-
level less than 2.5 mg/dL. Alcohol withdrawal, acidbase imbal- carbonate. It also may occur when too much acid is produced in
ances, and the use of antacids that bind with phosphate in the GI the body, for example, in diabetic ketoacidosis or starvation
tract are other possible causes of low serum phosphate levels. when fat tissue is broken down for energy. Metabolic acidosis
Manifestations of hypophosphatemia include paresthesias, mus- stimulates the respiratory center, and the rate and depth of res-
cle weakness and pain, mental changes, and possible seizures. pirations increase. Carbon dioxide is eliminated and carbonic
Hyperphosphatemia, defined in adults as a total serum phos- acid levels fall, minimizing the change in pH. This respiratory
phate level greater than 4.5 mg/dL, occurs when phosphate shifts compensation occurs within minutes of the pH imbalance.
out of the cells into extracellular fluids (e.g., due to tissue trauma
or chemotherapy for malignant tumors), in renal failure, or when Metabolic Alkalosis
excess phosphate is administered or ingested. Infants who are fed In metabolic alkalosis, the amount of bicarbonate in the body
cows milk are at risk for hyperphosphatemia, as are people using exceeds the normal 20-to-1 ratio. Ingestion of bicarbonate of
phosphate-containing enemas or laxatives. Clients who have high soda as an antacid is one cause of metabolic alkalosis. Another
koz74686_ch52.qxd 11/13/06 4:49 PM Page 1443
Pulmonary Bronchiole
artery branch Pulmonary
vein
CO2
O2
Alveolar wall
Capillary wall
O2
CO2
Red blood cell
O2 molecule
From Turley, Susan M., Medical Language, 1st ed., 2002. CO2 molecule
Reproduced with permission of Pearson Education, Inc., Blood
Upper Saddle River, New Jersey.
QUESTIONS
1. Hypoventilation can affect gas exchange. What are some causes of hypoventilation?
2. How does the shallow breathing from hypoventilation cause the PaCO2 to increase and the pH to decrease?
3. ABGs that indicate an increased PaCO2 and a decreased pH reflect which acidbase imbalance?
4. Hyperventilation can also affect gas exchange. What are some causes of hyperventilation?
5. How does hyperventilation cause a decreased PaCO2 and increased pH?
6. ABGs that indicate a decreased PaCO2 and an increased pH reflect which acidbase imbalance?
cause is prolonged vomiting with loss of hydrochloric acid from Nursing History
the stomach. The respiratory center is depressed in metabolic al- The nursing history is particularly important for identifying
kalosis, and respirations slow and become more shallow. Car- clients who are at risk for fluid, electrolyte, and acidbase im-
bon dioxide is retained and carbonic acid levels increase, balances. The current and past medical history reveal conditions
helping balance the excess bicarbonate. such as chronic lung disease or diabetes mellitus that can disrupt
The risk factors and manifestations for acidbase imbalances normal balances. Medications prescribed to treat acute or
are listed in Table 527. chronic conditions (e.g., diuretic therapy for hypertension) also
may place the client at risk for altered homeostasis. Functional,
developmental, and socioeconomic factors must also be consid-
NURSING MANAGEMENT ered in assessing the clients risk. Older people and very young
children, clients who must depend on others to meet their needs
Assessing for food and fluid intake, and people who cannot afford or do
Assessing clients for fluid, electrolyte, and acidbase balance not have the means to cook food for a balanced diet (e.g., home-
and imbalances is an important nursing care function. Compo- less people) are at greater risk for fluid and electrolyte imbal-
nents of the assessment include (a) the nursing history, (b) phys- ances. Common risk factors are listed in Box 523.
ical assessment of the client, (c) clinical measurements, and When obtaining the nursing history, the nurse needs to not
(d) review of laboratory test results. only recognize risk factors but also elicit data about the clients
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Metabolic Alkalosis
Excessive acid losses due to Decreased respiratory rate and depth Monitor intake and output closely.
Vomiting Dizziness Monitor vital signs, especially respirations, and
Gastric suction Circumoral paresthesias, numbness and LOC.
Excessive use of potassium-losing tingling of the extremities Administer ordered IV fluids carefully.
diuretics Hypertonic muscles, tetany Treat underlying problem.
Excessive adrenal corticoid hormones Laboratory findings:
due to Arterial blood pH above 7.45
Cushings syndrome
Serum bicarbonate greater than 26 mEq/L
Hyperaldosteronism
PaCO2 higher than 45 mm Hg with respiratory
Excessive bicarbonate intake from compensation
Antacids
Parenteral NaHCO3
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BOX 523 Common Risk Factors for Fluid, Electrolyte, and AcidBase Imbalances
CHRONIC DISEASES AND CONDITIONS MEDICATIONS
Chronic lung disease (COPD, asthma, cystic fibrosis) Diuretics
Heart failure Corticosteroids
Kidney disease Nonsteroidal anti-inflammatory drugs
Diabetes mellitus
TREATMENTS
Cushings syndrome or Addisons disease
Chemotherapy
Cancer
IV therapy and total parenteral nutrition
Malnutrition, anorexia nervosa, bulimia
Nasogastric suction
Ileostomy
Enteral feedings
ACUTE CONDITIONS Mechanical ventilation
Acute gastroenteritis
OTHER FACTORS
Bowel obstruction
Age: Very old or very young
Head injury or decreased level of consciousness
Inability to access food and fluids independently
Trauma such as burns or crushing injuries
Surgery
Fever, draining wounds, fistulas
food and fluid intake, fluid output, and the presence of signs or mation obtained in the nursing history. The focused physical
symptoms suggestive of altered fluid and electrolyte balance. assessment is summarized in Table 528 on page 1446. Refer
The Assessment Interview provides examples of questions to to Tables 525 through 528 for possible abnormal findings
elicit information regarding fluid, electrolyte, and acidbase related to specific imbalances.
balance.
Clinical Measurements
Physical Assessment Three simple clinical measurements that the nurse can initiate
without a primary care providers order are daily weights, vital
Physical assessment to evaluate a clients fluid, electrolyte,
signs, and fluid intake and output.
and acidbase status focuses on the skin, the oral cavity and
mucous membranes, the eyes, the cardiovascular and respira- DAILY WEIGHTS. Daily weight measurements provide a rela-
tory systems, and neurologic and muscular status. Data from tively accurate assessment of a clients fluid status. Significant
this physical assessment are used to expand and verify infor- changes in weight over a short time (e.g., more than 5 pounds
TABLE 528 Focused Physical Assessment for Fluid, Electrolyte, or AcidBase Imbalances
SYSTEM ASSESSMENT FOCUS TECHNIQUE POSSIBLE ABNORMAL FINDINGS
Skin Color, temperature, moisture Inspection, palpation Flushed, warm, very dry
Moist or diaphoretic
Cool and pale
Turgor Gently pinch up a fold of skin over Poor turgor: Skin remains tented for
sternum or inner aspect of thigh for several seconds instead of
adults, on the abdomen or medial immediately returning to normal
thigh for children position
Edema Inspect for visible swelling around Skin around eyes is puffy, lids appear
eyes, in fingers, and in lower swollen; rings are tight; shoes leave
extremities impressions on feet
Compress the skin over the dorsum Depression remains (pitting): see
of the foot, around the ankles, over scale for describing edema in
the tibia, in the sacral area Figure 52-11
Mucous membranes Color, moisture Inspection Mucous membranes dry, dull in
appearance; tongue dry and cracked
Eyes Firmness Gently palpate eyeball with lid closed Eyeball feels soft to palpation
Fontanels (infant) Firmness, level Inspect and gently palpate anterior Fontanel bulging, firm
fontanel Fontanel sunken, soft
Cardiovascular system Heart rate Auscultation, cardiac monitor Tachycardia, bradycardia; irregular;
dysrhythmias
Peripheral pulses Palpation Weak and thready; bounding
Blood pressure Auscultation of Korotkoffs sounds Hypotension
BP assessment lying and standing Postural hypotension
Capillary refill Palpation Slowed capillary refill
Venous filling Inspection of jugular veins and hand Jugular venous distention; flat jugular
veins veins, poor venous refill
Respiratory system Respiratory rate and pattern Inspection Increased or decreased rate and
depth of respirations
Lung sounds Auscultation Crackles or moist rales
Neurologic Level of consciousness (LOC) Observation, stimulation Decreased LOC, lethargy, stupor, or
coma
Orientation, cognition Questioning Disoriented, confused; difficulty
concentrating
Motor function Strength testing Weakness, decreased motor strength
Reflexes Deep-tendon reflex (DTR) testing Hyperactive or depressed DTRs
Abnormal reflexes Chvosteks sign: Tap over facial nerve Facial muscle twitching including
about 2 cm anterior to tragus of ear eyelids and lips on side of stimulus
Trousseaus sign: Inflate a blood Carpal spasm: contraction of hand
pressure cuff on the upper arm to and fingers on affected side
20 mm Hg greater than the systolic
pressure, leave in place for 2 to
5 minutes
in a week or less) are indicative of acute fluid changes. Each risk for fluid imbalance. For these clients, measuring intake and
kilogram (2.2 lb) of weight gained or lost is equivalent to 1 L output may be impractical because of lifestyle or problems with
of fluid gained or lost. Such fluid gains or losses indicate incontinence. Regular weight measurement, either daily, every
changes in total body fluid volume rather than in any specific other day, or weekly, provides valuable information about the
compartment, such as the intravascular compartment. Rapid clients fluid volume status.
losses or gains of 5% to 8% of total body weight indicate mod-
erate to severe fluid volume deficits or excesses. VITAL SIGNS. Changes in the vital signs may indicate, or in
To obtain accurate weight measurements, the nurse should bal- some cases precede, fluid, electrolyte, and acidbase imbal-
ance the scale before each use and weigh the client (a) at the same ances. For example, elevated body temperature may be a re-
time each day (e.g., before breakfast and after the first void), sult of dehydration or a cause of increased body fluid losses.
(b) wearing the same or similar clothing, and (c) on the same scale. Tachycardia is an early sign of hypovolemia. Pulse volume
The type of scale (i.e., standing, bed, chair) should be documented. will decrease in FVD and increase in FVE. Irregular pulse
Regular assessment of weight is particularly important for rates may occur with electrolyte imbalances. Changes in re-
clients in the community and extended care facilities who are at spiratory rate and depth may cause respiratory acidbase im-
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COMPLETE BLOOD COUNT (CBC). The complete blood specialized skills. Because a high-pressure artery is used to
MediaLink
count, another basic screening test, includes information about obtain blood, it is important to apply pressure to the puncture
the hematocrit (Hct). The hematocrit measures the volume site for 5 minutes after the procedure to reduce the risk of
(percentage) of whole blood that is composed of RBCs. Be- bleeding or bruising.
cause the hematocrit is a measure of the volume of cells in re- Six measurements are commonly used to interpret arterial
lation to plasma, it is affected by changes in plasma volume. blood gas tests (Simpson, 2004):
Thus the hematocrit increases with severe dehydration and de-
pH: a measure of the relative acidity or alkalinity of the
MediaLink
crease as the kidneys excrete hydrogen ions; in metabolic al- ing respiratory status, they generally do not provide useful in-
kalosis, the pH should increase. formation for assessing acidbase balance and so are not
included in this table.
URINE SPECIFIC GRAVITY. Specific gravity is an indicator of
When evaluating ABG results to determine acidbase bal-
urine concentration that can be performed quickly and easily by ance, it is important to use a systematic approach such as the one
nursing personnel. Normal specific gravity ranges from 1.005 to outlined in Box 527. Nurses need to assess each measurement
1.030 (usually 1.010 to 1.025). When the concentration of individually, then look at the interrelationships to determine
Diagnosing Risk for Imbalanced Fluid Volume: At risk for a decrease, in-
crease, or rapid shift from one to the other of intravascular,
NANDA includes the following diagnostic labels that relate to
interstitial, and/or intracellular fluid. This refers to body fluid
fluid and acidbase imbalances:
loss, gain, or both.
Deficient Fluid Volume: Decreased intravascular, interstitial, Risk for Deficient Fluid Volume: At risk for experiencing
and/or intracellular fluid. This refers to dehydration, water vascular, cellular, or intracellular dehydration.
loss alone without change in sodium. Impaired Gas Exchange: Excess or deficit in oxygenation and/or
Excess Fluid Volume: Increased isotonic fluid retention. carbon dioxide elimination at the alveolar-capillary membrane.
Clinical applications of selected diagnoses are shown in Prevent associated risks (tissue breakdown, decreased car-
MediaLink
Identifying Nursing Diagnoses, Outcomes, and Interventions diac output, confusion, other neurologic signs).
and in the Nursing Care Plan and the Concept Map at the end of
Obviously, goals will vary according to the diagnosis and
this chapter.
defining characteristics for each individual. Appropriate pre-
Fluid, electrolyte, and acidbase imbalances affect many
ventive and corrective nursing interventions that relate to these
other body areas and as a consequence may be the etiology of
must be identified. Specific nursing activities can be selected to
other nursing diagnoses, such as
meet the clients individual needs. Examples of application of
(c) fluid intake modifications; (d) dietary changes; (e) par- rals and home health services. The accompanying Home
enteral fluid, electrolyte, and blood replacement; and Care Assessment describes the specific assessment data re-
(f) other appropriate measures such as administering pre- quired to establish a home care plan. Based on the data gath-
scribed medications and oxygen, providing skin care and oral ered in assessment of the home situation, the nurse tailors the
hygiene, positioning the client appropriately, and scheduling teaching plan for the client and family (see Client Teaching
rest periods. on page 1453).
fluids and consume a balanced diet, but they may not under- Enteral Fluid and Electrolyte Replacement
stand the potential effects when this is not done. Nurses can pro- Fluids and electrolytes can be provided orally in the home and
mote clients health by providing wellness teaching that will hospital if the clients health permits, that is, if the client is not
help them maintain fluid and electrolyte balance. vomiting, has not experienced an excessive fluid loss, and has
CLIENT TEACHING Home Care and Fluid, Electrolyte, and AcidBase Balance
MONITORING FLUID INTAKE AND OUTPUT Teach the client and family how to care for intravenous access sites
Teach and provide the rationale for monitoring fluid intake and or gastric tubes. Include what to do if tubes become dislodged.
output to the client and family as appropriate. Include how to MEDICATIONS
use a commode or collection device (hat) in the toilet, how to Emphasize the importance of and rationale for taking medications
empty and measure urinary catheter drainage, and how to count as prescribed.
or weigh diapers. Instruct clients taking diuretics to take the medication in the morn-
Instruct and provide the rationale for regular weight monitoring
ing. If a second daily dose is prescribed, they should take it in the
to the client and family. Weigh at the same time of day, using the late afternoon to avoid disrupting sleep to urinate.
same scale and with the client wearing the same amount of Inform clients about any expected side effects of prescribed med-
clothing. ications and how to handle them (e.g., if a potassium-depleting di-
Educate and provide the rationale to the client and family on when
uretic is prescribed, increase intake of potassium-rich foods; if
to contact a health care professional, such as in the cases of a sig- taking a potassium-sparing diuretic, avoid excess potassium intake
nificant change in urine output; any change of 5 pounds or more such as using a salt substitute).
in a 1- to 2-week period; prolonged episodes of vomiting, diarrhea, Teach clients when to contact their primary care provider, for ex-
or inability to eat or drink; dry, sticky mucous membranes; extreme ample, if they are unable to take a prescribed medication or have
thirst; swollen fingers, feet, ankles, or legs; difficulty breathing, signs of an allergic or toxic reaction to a medication.
shortness of breath, or rapid heartbeat; and changes in behavior
or mental status. MEASURES SPECIFIC TO CLIENTS PROBLEM
Provide instructions and rationale specific to the clients fluid, elec-
MAINTAINING FOOD AND FLUID INTAKE
trolyte, or acidbase imbalance, such as
Instruct the client and family about any diet or fluid restrictions, a. Fluid volume deficit.
such as a low-sodium diet. b. Risk for fluid volume deficit.
Teach family members the rationale for the importance of offering
c. Fluid volume excess.
fluids regularly to clients who are unable to meet their own needs
because of age, impaired mobility or cognition, or other conditions REFERRALS
such as impaired swallowing due to a stroke. Make appropriate referrals to home health or community social ser-
If the client is on enteral or intravenous fluids and feeding at home, vices for assistance with resources such as meals, meal preparation
teach and provide the underlying rationale to caregivers about and food, intravenous infusions and access, enteral feedings, and
proper administration and care. Contact a home health or home homemaker or home health aide services to help with ADLs.
intravenous service to provide services and teaching. COMMUNITY AGENCIES AND OTHER SOURCES OF HELP
SAFETY Provide information about companies or agencies that can provide
Instruct and provide the rationale to the client to change positions durable medical equipment such as commodes, lift chairs, or hos-
slowly if appropriate, especially when moving from a supine to a pital beds for purchase, for rental, or free of charge.
sitting or standing position. Provide a list of sources for supplies such as catheters and
Inform and provide the rationale to the client and family about the drainage bags, measuring devices, tube feeding formulas, and
importance of good mouth and skin care. Teach the client to electrolyte replacement drinks.
change positions frequently and to elevate the feet on a stool Suggest additional sources of information and help such as the
when sitting for a long period. American Dietetic Association, the American Heart Association,
and the American Lung Association.
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1454
an intact gastrointestinal tract and gag and swallow reflexes. DIETARY CHANGES. Specific fluid and electrolyte imbal-
Clients who are unable to ingest solid foods may be able to in- ances may require simple dietary changes. For example,
gest fluids. clients receiving potassium-depleting diuretics need to be in-
formed about foods with a high potassium content (e.g., ba-
FLUID INTAKE MODIFICATIONS. Increased fluids (ordered as
nanas, oranges, and leafy greens). Some clients with fluid
push fluids) are often prescribed for clients with actual or
retention need to avoid foods high in sodium. Most healthy
potential fluid volume deficits arising, for example, from mild
clients can benefit from foods rich in calcium.
diarrhea or mild to moderate fevers. Guidelines for helping
clients increase fluid intake are shown in the above Practice ORAL ELECTROLYTE SUPPLEMENTS. Some clients can bene-
Guidelines. fit from oral supplements of electrolytes, particularly when a
Restricted fluids may be necessary for clients who have fluid medication is prescribed that affects electrolyte balance, when
retention (fluid volume excess) as a result of renal failure, con- dietary intake is inadequate for a specific electrolyte, or when
gestive heart failure, SIADH, or other disease processes. Fluid fluid and electrolyte losses are excessive as a result of, for ex-
restrictions vary from nothing by mouth to a precise amount ample, excessive perspiration.
ordered by a primary care provider. The restriction of fluids can Corticosteroids and many diuretics can cause too much
be difficult for some clients, particularly if they are experienc- potassium to be eliminated through the kidneys. For clients tak-
ing thirst. Guidelines for helping clients restrict fluid intake are ing these medications, potassium supplements may be pre-
shown in Practice Guidelines. scribed. Instruct clients taking oral potassium supplements to
take the medication with juice to mask the unpleasant taste and Parenteral Fluid and Electrolyte Replacement
reduce the possibility of gastric distress. Emphasize the impor-
Intravenous (IV) fluid therapy is essential when clients are un-
tance of taking the medication as prescribed and seeing their
able to take food and fluids orally. It is an efficient and effective
primary care provider on a regular basis. Because hyperkalemia
method of supplying fluids directly into the intravascular fluid
can have serious cardiac effects, clients should never increase
compartment and replacing electrolyte losses. Intravenous fluid
the amount of potassium being taken without an order to do so.
therapy is usually ordered by the primary care provider. The
In addition, inform clients that most salt substitutes contain
nurse is responsible for administering and maintaining the ther-
potassium, so it is important to consult with the primary care
apy and for teaching the client and significant others how to
provider before using salt substitutes.
continue the therapy at home if necessary.
People who ingest insufficient milk and milk products bene-
fit from calcium supplements. The recommended daily al- INTRAVENOUS SOLUTIONS. Intravenous solutions can be
lowance for calcium is 1,000 to 1,500 mg. It is generally classified as isotonic, hypotonic, or hypertonic. Most IV solu-
recommended that postmenopausal women take 1,500 mg of tions are isotonic, having the same concentration of solutes as
calcium per day to reduce the risk of osteoporosis. Long-term blood plasma. Isotonic solutions are often used to restore vas-
use of corticosteroid drugs can also cause calcium loss from the cular volume. Hypertonic solutions have a greater concentra-
bone, and calcium supplements may help reduce this loss. tion of solutes than plasma; hypotonic solutions have a lesser
Clients who take supplemental calcium need to maintain a fluid concentration of solutes. Table 5210 provides examples of IV
intake of at least 2,500 mL per day (unless contraindicated) to solutions and nursing implications.
reduce the risk of kidney stones, which are commonly com- IV solutions can also be categorized according to their pur-
posed of calcium salts. pose. Nutrient solutions contain some form of carbohydrate
Although routine supplements for other electrolytes gener- (e.g., dextrose, glucose, or levulose) and water. Water is sup-
ally are not recommended, clients who have poor dietary habits, plied for fluid requirements and carbohydrate for calories and
who are malnourished, or who have difficulty accessing or eat- energy. For example, 1 L of 5% dextrose provides 170 calories.
ing fresh fruits and vegetables may benefit from electrolyte sup- Nutrient solutions are useful in preventing dehydration and ke-
plements. A daily multiple vitamin with minerals may achieve tosis but do not provide sufficient calories to promote wound
the desired goal. People who engage in strenuous activity in a healing, weight gain, or normal growth in children. Common
warm environment need to be encouraged to replace water and nutrient solutions are 5% dextrose in water (D5W) and 5% dex-
electrolytes lost through excessive perspiration by consuming a trose in 0.45% sodium chloride (dextrose in half-strength
sports drink such as Gatorade or another commercial fluid and saline).
electrolyte solution. Electrolyte solutions contain varying amounts of cations and
Liquid nutritional supplements are often given to clients who anions. Commonly used solutions are normal saline (0.9%
are malnourished or have poor eating habits. They are used with sodium chloride solution), Ringers solution (which contains
frequency in older adults to bolster nutritional status and caloric sodium, chloride, potassium, and calcium), and lactated
intake. It is very important to be a label reader of the product Ringers solution (which contains sodium, chloride, potassium,
and to be aware of the contents of the supplement. Some of them calcium, and lactate). Lactate is metabolized in the liver to form
are very high in protein and high in potassium, which may be bicarbonate HCO3. Saline and balanced electrolyte solutions
contraindicated in an individual with impaired renal function. commonly are used to restore vascular volume, particularly
after trauma or surgery. They also may be used to replace fluid Cephalic vein
and electrolytes for clients with continuing losses, for example,
because of gastric suction or wound drainage. Basilic vein Median
Lactated Ringers solution is an alkalinizing solution that cubital
may be given to treat metabolic acidosis. Acidifying solutions, vein
Insertion site
in contrast, are administered to counteract metabolic alkalosis.
for PICC
Examples of acidifying solutions are 5% dextrose in 0.45%
sodium chloride and 0.9% sodium chloride solution.
Accessory
Volume expanders are used to increase the blood volume fol- Basilic vein cephalic vein
lowing severe loss of blood (e.g., from hemorrhage) or loss of
plasma (e.g., from severe burns, which draw large amounts of Medial Cephalic vein
antebrachial
plasma from the bloodstream to the burn site). Examples of ex-
vein
panders are dextran, plasma, and albumin.
Radial vein
VENIPUNCTURE SITES. The site chosen for venipuncture A
varies with the clients age, the length of time the infusion is
to run, the type of solution used, and the condition of veins.
For adults, veins in the hand and arm are commonly used; for
infants, veins in the scalp and dorsal foot veins are often used.
Larger veins are preferred for infusions that need to be given
rapidly and for solutions that could be irritating (e.g., certain
medications).
The metacarpal, basilic, and cephalic veins are commonly
used for intermittent or continuous infusions (Figure 52-16 , B Basilic vein
B). The ulna and radius act as natural splints at these sites, and
Cephalic vein
the client has greater freedom of arm movements for activities
such as eating. Although the basilic and median cubital veins in Dorsal venous
the antecubital space are convenient sites for venipuncture, they network
are usually used for blood draws, bolus injections of medica- Dorsal
tion, and insertion sites for a peripherally inserted central metacarpal veins
catheter line (see Figure 52-16 , A). See Practice Guidelines for
vein selection and general tips for easier IV starts.
When long-term IV therapy or parenteral nutrition is antici-
pated or the client is receiving IV medications that are damag-
ing to vessels (e.g., chemotherapy), a central venous catheter Figure 52-16 Commonly used venipuncture sites of the A, arm;
may be inserted. Central venous catheters usually are inserted B, hand. A also shows the site used for a peripherally inserted central
catheter (PICC).
into the subclavian or jugular vein, with the distal tip of the
catheter resting in the superior vena cava just above the right
atrium (Figure 52-17 ). They may be inserted at the clients
bedside or, for longer term access, surgically inserted. Subcla-
PRACTICE GUIDELINES Vein Selection vian central venous catheters permit freedom of movement for
ambulation; however, there is greater risk of complications, in-
Use distal veins of the arm first.
cluding hemothorax or pneumothorax, cardiac perforation,
Use the clients nondominant arm whenever possible.
Select a vein that is thrombosis, and infection. Assess the client closely for manifes-
a. Easily palpated and feels soft and full. tations such as shortness of breath, chest pain, cough, hypoten-
b. Naturally splinted by bone. sion, tachycardia, and anxiety after the insertion procedure.
c. Large enough to allow adequate circulation around the With a peripherally inserted central venous catheter (PICC),
catheter. the catheter is inserted in the basilic or cephalic vein just above
Avoid using veins that are or below the antecubital space of the right arm. The tip of the
a. In areas of flexion (e.g., the antecubital fossa). catheter rests in the superior vena cava. The risk of pneumotho-
b. Highly visible, because they tend to roll away from the rax is eliminated with PICC. These catheters frequently are used
needle. for long-term intravenous access when the client will be man-
c. Damaged by previous use, phlebitis, infiltration, or sclerosis.
aging IV therapy at home.
d. Continually distended with blood, or knotted or tortuous.
Implantable venous access devices or ports (Figures 52-18
e. In a surgically compromised or injured extremity (e.g., fol-
lowing a mastectomy), because of possible impaired cir- and 52-19 on page 1458) are used for clients with chronic ill-
culation and discomfort for the client. ness who require long-term IV therapy (e.g., intermittent med-
ications such as chemotherapy, total parenteral nutrition, and
koz74686_ch52.qxd 11/13/06 4:49 PM Page 1457
frequent blood samples). The device is designed to provide re- cutaneous pocket under the skin, usually on the anterior chest
peated access to the central venous system, avoiding the trauma near the clavicle, and no part of the port is exposed. The distal
and complications of multiple venipunctures. Using local anes- end of the catheter is placed in the subclavian or jugular vein.
thesia, implantable ports are surgically placed into a small sub- There are different kinds of implantable venous access devices
and they may be tunneled or nontunneled (Rosenthal, 2005b).
Special precautions need to be taken with all central lines and
Catheter venous access ports to ensure asepsis and catheter patency.
Nursing care of clients with these devices is outlined in Practice
Subclavian vein Superior vena cava Guidelines on page 1459.
INTRAVENOUS EQUIPMENT. Because equipment varies ac-
cording to the manufacturer, the nurse must become familiar
with the equipment used in each particular agency.
Solution containers are available in various sizes (50, 100,
250, 500, or 1,000 mL); the smaller containers are often used to
A
administer medications. Most solutions are currently dispensed
in plastic bags (Figure 52-20 ). However, glass bottles may
Catheter need to be used if the administered medications are incompati-
Internal jugular ble with plastic. Glass bottles require an air vent so that air can
vein enter the bottle and replace the fluid that enters the clients vein.
Subclavian vein Some have a tube inside the bottle that serves as a vent; other
Superior containers without air vents require a vent on the administration
vena cava
set. Air vents usually have filters to prevent contamination from
the air that enters the container. Air vents are not required for
plastic solution bags, because the bags collapse under atmos-
pheric pressure when the solution enters the vein.
It is essential that the solution be sterile and in good condi-
B tion, that is, clear. Cloudiness, evidence that the container has
Figure 52-17 Central venous lines with A, subclavian vein insertion, been opened previously, or leaks indicate possible contamina-
and B, left jugular insertion. tion. Always check the expiration date on the label. Return any
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1458
Catheter
Self-sealing septum
Lock
Skin
Secondary
Clamp port
Secondary
port
Clamp
mation is found on the package. There are also 60 drops sets, in-line filter to trap air, particulate matter, and microbes. A spe-
which deliver microdrip per milliliter of solution. The roller cial infusion set may be required if the IV flow rate will be reg-
valve or screw clamp, which compresses the lumen of the tub- ulated by an infusion pump.
ing, controls the rate of the flow. The protective cap over the nee- Catheters and needles are commonly used for intravenous
dle adapter maintains the sterility of the end of the tubing so that infusions. Over-the-needle catheters, also known as angio-
it can be attached to a sterile needle inserted in the clients vein. caths, are commonly used for adult clients. The plastic
Most infusion sets include one or more injection ports for ad- catheter fits over a needle used to pierce the skin and vein wall
ministering IV medications or secondary infusions. Needleless (Figure 52-23 ). Once inserted into the vein, the needle is
systems are increasingly used because they reduce the risk of withdrawn and discarded, leaving the catheter in place. IV
needlestick injury and contamination of the intravenous line. catheters allow the client more mobility and rarely infiltrate,
There are various types of needleless systems available, includ- that is, become dislodged from the vein and allow fluid to flow
ing two-piece prepierced septum and blunt cannula devices, into interstitial spaces.
Luer-activated devices, and three-way pressure-activated safety Safety devices on IV catheters are now common. With the orig-
valves (Rosenthal, 2003). With each of these needleless sys- inal over-the-needle catheters, the sharp stylet remained exposed
tems, a blunt cannula is inserted into a special injection port or until placed in a sharps container. This resulted in needlestick in-
adapter on the IV tubing to administer medications or second- juries to nurses. The 2000 Needlestick Safety and Prevention Act
ary infusions (Figure 52-22 ). Many infusion sets include an requires the use of needle saftey devices to prevent exposure to
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1460
A B
Figure 52-22 Cannulae used to connect the tubing of additive sets to primary infusions: A, threaded-lock cannula; B, lever-lock cannula.
(Photographs reprinted courtesy of (BD) Becton, Dickinson and Company and courtesy of Baxter Healthcare Corporation. All rights reserved.)
Tapered
catheter tip
Luer lock Finger Needle bevel
tabs guard position indicator
bloodborne pathogens (Wilburn, 2004). The safety devices for IV or hang from the ceiling. In the home, plant hangers or robe
catheters vary. They can be either an active safety device which re- hooks (even kitchen cabinet knobs or an S-hook over the top
quires activation by the nurse or a passive safety device where the of a door) may be used to hang solution containers. The
safety feature is automatically activated after the sytlet is removed height of most poles is adjustable. The higher the solution
from the catheter. container, the greater the force of the solution as it enters the
Butterfly, or wing-tipped, needles with plastic flaps attached to client and the faster the rate of flow.
the shaft are sometimes used (Figure 52-24 ). The flaps are held
tightly together to hold the needle securely during insertion; after STARTING AN INTRAVENOUS INFUSION. Although the pri-
insertion, they are flattened against the skin and secured with tape. mary care provider is responsible for ordering IV therapy for
IV poles are used to hang the solution container. Some clients, nurses initiate, monitor, and maintain the prescribed
poles are attached to hospital beds; others stand on the floor IV infusion. This is true not only in hospitals and long-term
care facilities but increasingly in community-based settings
such as clinics and clients homes.
Before starting an infusion, the nurse determines the following:
Cap for needle
Stem
The type and amount of solution to be infused
Plastic
The exact amount (dose) of any medications to be added to a
adapter
compatible solution
Wings
The rate of flow or the time over which the infusion is to be
completed
SKILL 52-1
care providers order indicating the type of solution, the amount to allergies (e.g., to tape or povidone-iodine).
Skin turgor
PLANNING Equipment
Prior to initiating the IV infusion, consider how long the client is likely Infusion set
to have the IV, what kinds of fluids will be infused, and what medica- Sterile parenteral solution
tions the client will be receiving or is likely to receive. These factors IV pole
may affect the choice of vein and catheter size. Adhesive or nonallergenic tape
Clean gloves
Delegation Tourniquet
This procedure is done by a registered nurse and, in many states, Antiseptic swabs
by a licensed pratical nurse or licensed vocational nurse. Check Antiseptic ointment (check agency policy)
the states nurse practice act. Due to the use of sterile technique, Intravenous catheter; see Variation at the end of this procedure
intravenous infusion therapy is not delegated to unlicensed as- for a butterfly (winged-tip) needle
sistive personnel (UAP). UAP may care for clients receiving IV Sterile gauze dressing or transparent occlusive dressing
therapy, and the nurse must ensure that the UAP knows how to Arm splint, if required
perform routine tasks such as bathing and positioning without Towel or pad
disturbing the IV. The UAP should also know what complications Electronic infusion device or pump (The nurse decides what de-
or adverse signs, such as leakage, should be reported to the vice is needed as appropriate to the clients condition.)
nurse. In some states a licensed vocational nurse with special IV
therapy training may start intravenous infusions.
IMPLEMENTATION Performance
Preparation Perform hand hygiene.
1. Prepare the client. 1. Open and prepare the infusion set.
Prior to performing the procedure, introduce self and verify Remove tubing from the container and straighten it out.
the clients identity using agency protocol. Explain the proce- Slide the tubing clamp along the tubing until it is just below
dure to the client. A venipuncture can cause discomfort for the drip chamber to facilitate its access.
a few seconds, but there should be no discomfort while the Close the clamp.
solution is flowing. Use a doll to demonstrate for children, Leave the ends of the tubing covered with the plastic caps
and explain the procedure to the parents. Clients often want until the infusion is started. Rationale: This will maintain the
to know how long the process will last. The primary care sterility of the ends of the tubing.
providers order may specify the length of time of the infu- 2. Spike the solution container.
sion, for example, 3,000 mL over 24 hours. Remove the protective cover from the entry site of the bag.
Unless initiating IV therapy is urgent, provide any scheduled Remove the cap from the spike and insert the spike into the
care before establishing the infusion to minimize movement insertion site of the bag or bottle. Follow the manufac-
of the affected limb during the procedure. Moving the limb af- turers instructions.
ter the infusion has been established could dislodge the 3. Apply a medication label to the solution container if a medica-
catheter. tion is added.
Make sure that the clients clothing or gown can be removed In many agencies, medications and labels are applied in the
over the IV apparatus if necessary. Some agencies provide pharmacy; if they are not, apply the label upside down on
special gowns that open over the shoulder and down the the container. Rationale: The label is applied upside down
sleeve for easy removal. so it can be read easily when the container is hanging up.
peripheral lines.
Reclamp the tubing and replace the tubing cap, maintaining
sterile technique.
For caps with air vents, do not remove the cap when prim-
ing this tubing. The flow of solution through the tubing will
cease when the cap is moist with one drop of solution.
If an infusion control pump, electronic device, or controller is
Adjust the pole so that the container is suspended about hairy. Shaving is not usually recommended because of the
1 m (3 ft) above the clients head. Rationale: This height is potential for microabrasions which can increase the risk
needed to enable gravity to overcome venous pressure and of infection.
facilitate flow of the solution into the vein. Place a towel or bed protector under the extremity to protect
6. Partially fill the drip chamber with solution. linens (or furniture if in the home).
Squeeze the chamber gently until it is half full of solution. 10. Dilate the vein.
7. Prime the tubing. Place the extremity in a dependent position (lower than the
Remove the protective cap and hold the tubing over a con- clients heart). Rationale: Gravity slows venous return and
tainer. Maintain the sterility of the end of the tubing and the distends the veins. Distending the veins makes it easier to
cap. insert the needle properly.
Release the clamp and let the fluid run through the tubing un- Apply a tourniquet firmly 15 to 20 cm (6 to 8 in.) above the
til all bubbles are removed. Tap the tubing if necessary with venipuncture site. Explain that the tourniquet will feel
your fingers to help the bubbles move. Rationale: The tub- tight. Rationale: The tourniquet must be tight enough to ob-
ing is primed to prevent the introduction of air into the client. struct venous flow but not so tight that it occludes arterial
flow. Obstructing arterial flow inhibits venous filling. If a ra-
dial pulse can be palpated, the arterial flow is not obstructed.
Use the tourniquet on only one client. This avoids cross-
contamination to other clients.
B
Squeezing the drip chamber.
Photographer: Elena Dorfman Applying a tourniquet.
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1463
SKILL 52-1
a. Massage or stroke the vein distal to the site and in the di- angle with bevel up, insert the catheter through the skin and
rection of venous flow toward the heart. Rationale: This into the vein. Sudden lack of resistance is felt as the needle
action helps fill the vein. enters the vein. Jabbing, stabbing, or quick thrusting should
b. Encourage the client to clench and unclench the fist. be avoided because it may cause rupture of delicate veins
Rationale: Contracting the muscles compresses the dis- (Phillips, 2005).
tal veins, forcing blood along the veins and distending Once blood appears in the lumen of the needle or you feel
them. the lack of resistance, lower the angle of the catheter until it
c. Lightly tap the vein with your fingertips. Rationale: is almost parallel with the skin, and advance the needle and
Tapping may distend the vein. catheter approximately 0.5 to 1 cm (about 1/4 in.) farther.
If the preceding steps fail to distend the vein so that it is pal- Holding the needle portion steady, advance the catheter un-
pable, remove the tourniquet and wrap the extremity in a til the hub is at the venipuncture site. The exact technique
warm, moist towel for 10 to 15 minutes. Rationale: Heat di- depends on the type of device used. Rationale: The
lates superficial blood vessels, causing them to fill. Then re- catheter is advanced to ensure that it, and not just the metal
peat step 10. needle, is in the vein. The exact technique depends on the
11. Put on clean gloves and clean the venipuncture site. type of catheter used.
Rationale: Gloves protect the nurse from contamination by Release the tourniquet.
the clients blood. Put pressure on the vein proximal to the catheter to elimi-
Clean the skin at the site of entry with a topical antiseptic swab nate or reduce blood oozing out of the catheter. Stabilize the
(e.g., 2% chlorhexidine, or alcohol). Some institutions may hub with thumb and index finger of the nondominant hand.
use an anti-infective solution such as povidone-iodine (check Remove the protective cap from the distal end of the tubing
agency protocol). Check for allergies to iodine or shellfish be- and hold it ready to attach to the catheter, maintaining the
fore cleansing skin with Betadine or iodine products. sterility of the end.
Use a circular motion, moving from the center outward for Carefully remove the needle, engage the needle safety device,
several inches. Rationale: This motion carries microorgan- and attach the end of the infusion tubing to the catheter hub.
isms away from the site of entry. Initiate the infusion.
Permit the solution to dry on the skin. Povidone-iodine should 13. Tape the catheter.
be in contact with the skin for 1 minute to be effective. Tape the catheter by the U method or according to the
12. Insert the catheter and initiate the infusion. manufacturers instructions. Using three strips of adhesive
If desired and permitted by policy, inject 0.05 mL of 1% li- tape, each about 7.5 cm (3 in.) long:
docaine intradermally over the site where you plan to insert a. Place one strip, sticky side up, under the catheters hub.
the IV needle. Allow 5 to 10 seconds for the anesthetic to b. Fold each end over so that the sticky sides are against the
take effect. Transdermal analgesic creams (e.g., ELA-Max, skin.
EMLA) may also be used, depending on policy. Allow 30 c. Place the second strip, sticky side down, over the catheter
minutes for the transdermal analgesic to take effect. hub.
Use the nondominant hand to pull the skin taut below the d. Place the third strip, sticky side down, over the tubing hub.
entry site. Rationale: This stabilizes the vein and makes the 14. Dress and label the venipuncture site and tubing according to
skin taut for needle entry. It can also make initial tissue pen- agency policy.
etration less painful. Unless there is an allergy, a sterile transparent occlusive
gauge of catheter used, and your initials. Follow the course of the vein, and pierce one side of the vein. Sud-
15. Ensure appropriate infusion flow. den lack of resistance can be felt as blood enters the needle.
Apply a padded arm board to splint the joint, as needed.
When blood flows back into the needle tubing, insert the nee-
Adjust the infusion rate of flow according to the order.
dle to its hub.
16. Label the IV tubing. Release the tourniquet, attach the infusion, and initiate flow as
Label the tubing with the date and time of attachment and
quickly as possible. Rationale: Attaching the tubing quickly pre-
your initials. This labeling may also be done when the in- vents blood from clotting and obstructing the needle.
fusion is started. Rationale: The tubing is labeled to ensure Secure the butterfly needle by taping it securely by the crisscross
(chevron) method. Place a small gauze square under the
needle, if required. Rationale: The gauze keeps the needle in
position in the vein.
Needle in vein
Tape
Tubing
72 HRS.ONLY
I.V. SET__
0800
9/11 HR._____
START DATE________
9/14 HR._____
DISCARD DATE______ 0800
LA
R.N. INITIAL_________________
SKILL 52-1
EVALUATION IV flow rate consistent with that ordered
Evaluate the following: Ability to perform self-care activities; understanding of any mo-
Skin status at IV site (warm temperature and absence of pain, bility limitations
redness, and swelling) Vital signs compared to baseline level
Status of dressing
REGULATING AND MONITORING INTRAVENOUS INFUSIONS. in hours. For example, if 3,000 mL is infused in 24 hours, the
Orders for IV infusions may take several forms: 3,000 mL over number of milliliters per hour is
24 hours; 1,000 mL every 8 hours 3 bags; 125 mL/h un-
3,000 mL (total infusion volume)
til oral intake is adequate. The nurse initiating the IV calculates 125 mL/h
24 h (total infusion time)
the correct flow rate, regulates the infusion, and monitors the
clients responses. Unless an infusion control device is used, the Nurses need to check infusions at least every hour to ensure that
nurse manually regulates the drops per minute of flow using the the indicated milliliters per hour have infused and that IV patency
roller clamp to ensure that the prescribed amount of solution is maintained. A strip of adhesive marking the exact time and/or
will be infused in the correct time span. If the flow is incorrect, amount to be infused may be taped to the solution container. Some
problems such as hypervolemia, hypovolemia, or inadequate agencies make premarked labels available (Figure 52-26 ).
medication administration can result.
Drops per Minute. The nurse initiating and monitoring an in-
The number of drops delivered per milliliter of solution
fusion must regulate the drops per minute to ensure that the pre-
varies with different brands and types of infusion sets. This
scribed amount of solution will infuse. Drops per minute are
rate, called the drip factor (sometimes called the drop factor),
calculated by the following formula:
generally is printed on the package of the infusion set. Macro-
drops commonly have drop factors of 10, 12, 15, or 20 Total infusion volume drop factor
drops/mL; the drop factor for microdrip is always 60 Drops per minute Total time of infusion in minutes
drops/mL (Figure 52-25 ).
If the requirements are 1,000 mL in 8 hours and the drip factor
To calculate flow rates, the nurse must know the volume of
is 20 drops/mL, the drops per minute should be
fluid to be infused and the specific time for the infusion. Two
commonly used methods of indicating flow rates are designat- 1,000 mL 20 41 drops/min
ing the number of milliliters to be administered in 1 hour (mL/h) 8 60 min (480 min)
and the number of drops to be given in 1 minute (gtt/min). Be-
Approximating this rate as 40 drops/min, the nurse regulates the
cause l milliliter of fluid displaces 1 cubic centimeter of space,
drops per minute by tightening or releasing the IV tubing clamp
the volume to be infused in the first method may also be desig-
and counting the drops for 15 seconds, then multiplying that
nated as cubic centimeters per hour (cc/h).
number by 4 (e.g., 10 drops/15 sec).
Milliliters per Hour. Hourly rates of infusion can be calculated A number of factors influence flow rate (see Box 528).
by dividing the total infusion volume by the total infusion time
Figure 52-27 The Dial-A-Flo in-line device. Figure 52-29 Programmable infusion pumps.
Photographer: Elena Dorfman (Courtesy of ALARIS Medical Systems, Inc., San Diego, California.)
koz74686_ch52.qxd 11/8/06 2:08 PM Page 1467
SKILL 52-2
To maintain the prescribed flow rate
To prevent complications associated with IV therapy
ASSESSMENT
Assess the following:
Appearance of infusion site; patency of system
Type of fluid being infused and rate of flow
Response of the client
PLANNING Delegation
Review the type of equipment used outside the clients room. Read This procedure should be done by the nurse because it is an im-
all appropriate materials and confirm the type of tubing, controller, or portant part of assessment and complications may occur.
pump being used.
From the primary care providers order, determine the type the chamber to allow the correct amount of fluid to flow in.
and sequence of solutions to be infused. Open the drip regulator and observe for a rapid flow of fluid
Determine the rate of flow and infusion schedule. from the solution container into the drip chamber. Then
partially close the drip regulator to reestablish the pre-
Performance
scribed rate of flow. Rationale: Rapid flow of fluid into the
1. Ensure that the correct solution is being infused.
drip chamber indicates patency of the IV line. Closing the
If the solution in incorrect, slow the rate of flow to a mini-
drip regulator to the prescribed rate of flow prevents fluid
mum to maintain the patency of the catheter. Rationale:
overload.
Stopping the infusion may allow a thrombus to form in the
Inspect the tubing for pinches or kinks or obstructions to
IV catheter. If this occurs, the catheter must be removed and
flow. Arrange the tubing so that it is lightly coiled and under
another venipuncture performed before the infusion can be
no pressure. Sometimes the tubing becomes caught under
resumed.
the clients body and the weight blocks the flow.
Change the solution to the correct one. Document and re-
Observe the position of the tubing. If it is dangling below the
port the error according to agency protocol.
venipuncture, coil it carefully on the surface of the bed.
2. Observe the rate of flow every hour.
Rationale: The solution may not flow upward into the vein
Compare the rate of flow regularly, for example, every hour,
against the force of gravity.
against the infusion schedule. Rationale: Infusions that are
Lower the solution container below the level of the infusion
off schedule can be harmful to a client.
site and observe for a return flow of blood from the vein.
If the rate is too fast, slow it so that the infusion will be com-
Rationale: A return flow of blood indicates that the needle
pleted at the planned time. Rationale: Solution administered
is patent and in the vein. Blood returns in this instance be-
too quickly may cause a significant increase in circulating
cause venous pressure is greater than the fluid pressure in
blood volume (which is about 6 L in an adult). Hypervolemia
the IV tubing. Absence of blood return may indicate that the
may result in pulmonary edema and cardiac failure. Assess
needle is no longer in the vein or that the tip of the catheter
the client for manifestations of hypervolemia and its compli-
is partially obstructed by a thrombus, the vein wall, or a
cations, including dyspnea; rapid, labored breathing; cough;
valve in the vein.
crackles (rales) in the lung bases; tachycardia; and bounding
Determine whether the bevel of the catheter is blocked
pulses.
against the wall of the vein. If it is blocked, pull back gently,
If the rate is too slow, check agency practice. Some agencies
turn it slightly, or carefully raise or lower the angle of inser-
permit nursing personnel to adjust a rate of flow by a speci-
tion slightly, using a sterile gauze pad underneath to protect
fied amount. Adjustments above this rate require a primary
the skin and change the position of the catheter bevel.
care providers order. Rationale: Solution that is adminis-
If there is leakage, locate the source. If the leak is at the
tered too slowly can supply insufficient fluid, electrolytes, or
catheter connection, tighten the tubing into the catheter. If
medication for a clients needs.
the leak cannot be stopped, slow the infusion as much as
If the rate of flow is 150 mL/h or more, check the rate of flow
possible without stopping it, and replace the tubing with a
more frequently, for example, every 15 to 30 minutes.
new sterile set. Estimate the amount of solution lost, if it was
3. Inspect the patency of the IV tubing and catheter.
substantial.
Observe the position of the IV solution. If it is less than 1 m
4. Inspect the insertion site for fluid infiltration.
(3 ft) above the IV site, readjust it to the correct height of the
When an IV needle becomes dislodged from the vein, fluid
pole. Rationale: If the IV bag/bottle is too low, the solution
flows into interstitial tissues, causing swelling. This is known
may not flow into the vein because there is insufficient grav-
as infiltration and is manifested by localized swelling, cool- of mechanical trauma or chemical irritation. Chemical injury
SKILL 52-2
ness, pallor, and discomfort at the IV site. to a vein can occur from intravenous electrolytes (especially
If an infiltration is present, stop the infusion and remove the potassium and magnesium) and medications. The clinical
catheter. Restart the infusion at another site. signs are redness, warmth, and swelling at the intravenous
Apply a warm compress to the site of the infiltration. Ration- site and burning pain along the course of a vein.
ale: Warmth promotes comfort and vasodilation, facilitating If phlebitis is detected, discontinue the infusion, and apply
absorption of the fluid from interstitial tissues. warm compresses to the venipuncture site. Do not use this
5. If the infiltration involves a vesicant drug, it is called extravasa- injured vein for further infusions.
tion and other measures may be indicated. Extravasated vesi- 8. Inspect the intravenous site for bleeding.
cant drugs can cause severe tissue injury or destruction. The Oozing or bleeding into the surrounding tissues can occur
extravasation of a vesicant drug should be considered an emer- while the infusion is freely flowing but is more likely to occur
gency (Hadaway, 2004). after the needle has been removed from the vein.
Stop the infusion immediately. Disconnect the tubing as Observation of the venipuncture site is extremely important
close to the catheter hub as possible and attempt to aspirate for clients who bleed readily, such as those receiving antico-
any drug remaining in the hub. If an injectable antidote is agulants.
available, the catheter should remain in place. 9. Teach the client ways to maintain the infusion system, for
The primary care provider should be notified and if ordered, example:
the antidote administered. Avoid sudden twisting or turning movements of the arm with
The affected arm should be elevated and depending on the the needle or catheter.
drug, heat or cold therapy should be implemented. Avoid stretching or placing tension on the tubing.
6. If infiltration is not evident but the infusion is not flowing, de- Try to keep the tubing from dangling below the level of the
will cause blood to flow (flash back) into the tubing if the a. The flow rate suddenly changes or the solution stops
needle is in the vein. dripping.
Use a sterile syringe of saline to withdraw fluid from the port b. The solution container is nearly empty.
near the venipuncture site. If blood does not return, discon- c. There is blood in the IV tubing.
tinue the intravenous solution. d. Discomfort or swelling is experienced at the IV site.
7. Inspect the insertion site for phlebitis (inflammation of a vein). 10. Document all relevant information.
Inspect and palpate the site at least every 8 hours. Phlebitis
Intactness of IV system Vital signs and lung sounds compared to baseline data
CHANGING INTRAVENOUS CONTAINERS, TUBING, AND all IV bags should be changed every 24 hours, regardless of
DRESSINGS. Intravenous solution containers are changed how much solution remains, to minimize the risk of contami-
when only a small amount of fluid remains in the neck of the nation. IV tubing is changed every 48 to 96 hours, depending
container and fluid still remains in the drip chamber. However, on agency protocol, as is the site dressing. Skill 52-3 provides
To maintain the flow of required fluids To prevent infection at the IV site and the introduction of mi-
To maintain sterility of the IV system and decrease the incidence croorganisms into the bloodstream
of phlebitis and infection
SKILL 52-3
Review primary care providers orders for changes in fluid administration. Sterile gauze square for positioning the needle
1. Obtain the correct solution container. mation. Rationale: Inflammation or infiltration necessitates
Read the label of the new container. removal of the IV needle or catheter to avoid further trauma
Verify that you have the correct solution, correct client, cor- to the tissues.
rect additives (if any), and correct dose (number of bags or Go to step 6, or discontinue and relocate the IV site if indi-
microorganisms present at the site, thus reducing the risk of Place the date and time of the dressing change and your ini-
SKILL 52-3
infection. tials either on the label provided or directly over the top of
Follow agency protocol about cleaning procedures. the dressing.
10. Retape the needle or catheter. Secure IV tubing with additional tape as required.
For a butterfly needle, apply strips of tape to the wings of 12. Regulate the rate of flow of the solution according to the order
the butterfly using the crisscross (chevron) method on the chart.
(Figure in Skill 52-1). 13. Document all relevant information.
For a catheter; apply the tape using the U method Record the change of the solution container, tubing, and/or
(Figure in Skill 52-1). dressing in the appropriate place on the clients chart. Also
Apply a sterile transparent dressing over the site. record the fluid intake according to agency practice. Record
Remove gloves. the number of the container if the containers are numbered
11. Label the dressing and secure IV tubing. at the agency. Also record your assessments.
EVALUATION
Evaluate the following:
Status of IV site
Patency of IV system
Accuracy of flow
guidelines for changing an IV solution container, tubing, and moved or the catheter is left in place and converted to a saline
the IV site dressing. or heparin lock. Guidelines for discontinuing an IV infusion or
When an IV infusion is no longer necessary to maintain the converting the catheter to a lock are outlined in Skills 52-4 and
clients fluid intake or to provide a route for medication admin- 52-5, respectively.
istration, the infusion is either discontinued and the catheter re-
To discontinue an intravenous infusion when the therapy is complete or when the IV site needs to be changed
PLANNING Equipment
Review the primary care providers orders. Clean gloves
Dry or antiseptic-soaked swabs, according to agency practice
Delegation Small sterile dressing and tape
This procedure should be done by a registered nurse. In many
states, licensed vocational nurses may initiate and discontinue IV
therapy.
Clamp the infusion tubing. Rationale: Clamping the tubing venipuncture site.
prevents the fluid from flowing out of the needle onto the 2. Withdraw the needle or catheter from the vein.
client or bed. Withdraw the needle or catheter by pulling it out along the
Loosen the tape at the venipuncture site while holding the line of the vein. Rationale: Pulling it out in line with the vein
needle firmly and applying countertraction to the skin. avoids injury to the vein.
Rationale: Movement of the needle can injure the vein and
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SKILL 52-4
gauze, for 2 to 3 minutes. Rationale: Pressure helps stop care provider is notified.
the bleeding and prevents hematoma formation. 4. Cover the venipuncture site.
Hold the clients arm above the body if any bleeding persists. Apply the sterile dressing. Rationale: The dressing continues
Rationale: Raising the limb decreases blood flow to the area. the pressure and covers the open area in the skin, prevent-
3. Examine the catheter removed from the client. ing infection.
Check the catheter to make sure it is intact. Rationale: If a Discard the IV solution properly, if infusions are being discon-
piece of tubing remains in the clients vein it could move tinued, and discard the used supplies appropriately.
centrally (toward the heart or lungs) and cause serious 5. Document all relevant information.
problems. Record the amount of fluid infused on the intake and output
Report a broken catheter to the nurse in charge or primary record and on the chart, according to agency practice. In-
care provider immediately. clude the container number, type of solution used, time of
If a broken piece can be palpated, apply a tourniquet above discontinuing the infusion, and the clients response.
the insertion site. Rationale: Application of a tourniquet de-
EVALUATION Respirations, skin color, edema, sputum, cough, and urine output
Evaluate the following: How the person feels physically and psychologically
Appearance of the venipuncture site
The pulse
SKILL 52-5
ASSESSMENT
Assess the following:
Patency of the IV catheter
Appearance of the site (evidence of inflammation or infiltration)
PLANNING Equipment
Review the primary care providers order. Intermittent infusion cap or device
IMPLEMENTATION Performance
Preparation 1. Prepare the equipment.
1. Prepare the client. Perform hand hygiene.
Prior to performing the procedure, introduce self and verify Assess the IV site (if visible) and determine the patency of
the clients identity using agency protocol. Explain the proce- the catheter (see Skill 52-2). If the catheter is not fully patent
dure to the client and the reason for leaving the IV catheter or there is evidence of phlebitis or infiltration, discontinue
in place. Changing an IV to a heparin or saline lock should the catheter and establish a new IV site.
cause no discomfort other than that associated with remov-
ing tape from the IV tubing.
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Expose the IV catheter hub and loosen any tape that is hold- 3. Instill saline or heparin solution per agency policy. Rationale:
SKILL 52-5
ing the IV tubing in place or that will interfere with insertion Saline or heparin are used to maintain patency of the IV
of the intermittent infusion plug into the catheter. catheter when fluids are not infusing through the catheter.
Clamp the IV tubing to stop the flow of IV fluid. 4. Tape the intermittent infusion plug in place using a chevron or
Open the gauze pad and place it under the IV catheter hub. U method. Rationale: Tape provides added security to pre-
Open the alcohol wipe and intermittent infusion plug, leav- vent the infusion plug from coming out of the intravenous
ing the plug in its sterile package. catheter. It also promotes comfort, preventing the plug from
2. Remove the IV tubing and insert the intermittent infusion plug catching on clothing or bedding.
into the IV catheter. 5. Teach the client how to maintain the lock.
Put on gloves. Avoid manipulating the catheter or infusion plug and protect
Stabilize the IV catheter with your nondominant hand and it from catching on clothing or bedding. A gauze bandage
use the little finger to place slight pressure on the vein above such as Kerlix or Kling may be wrapped over the plug when
the end of the catheter. Twist the IV tubing adapter to loosen it is not in use to protect it.
it from the IV catheter and remove it, placing the end of the Cover the site with an occlusive dressing when showering;
remove the protective sleeve from the male adapter, main- Notify the nurse or primary care provider if the plug or
taining its sterility. Insert the plug into the IV catheter, twist- catheter comes out; if the site becomes red, inflamed, or
ing it to seat it firmly or engage the Luer lock. painful; or if any drainage or bleeding occurs at the site.
6. Document all relevant information.
EVALUATION
Evaluate the following:
Patency of the catheter
Appearance of the site
Ease of flushing
Blood Transfusions as antigens that are unique for each person. Many blood anti-
gens have been identified, but the antigens A, B, and Rh are
Intravenous fluids can be effective in restoring intravascular
the most important in determining blood group or type. Be-
(blood) volume; however, they do not affect the oxygen-
cause antigens promote agglutination or clumping of blood
carrying capacity of the blood. When red and white blood
cells, they are also known as agglutinogens. The A antigen or
cells, platelets, or blood proteins are lost because of hemor-
agglutinogen is present on the RBCs of people with blood
rhage or disease, it may be necessary to replace these compo-
group A, the B antigen is present in people with blood group
nents to restore the bloods ability to transport oxygen and
B, and both A and B antigens are found on the RBC surface in
carbon dioxide, to clot, to fight infection, and to keep extra-
people with group AB blood. Neither antigen is present in peo-
cellular fluid within the intravascular compartment. A blood
ple with group O blood.
transfusion is the introduction of whole blood or blood com-
Preformed antibodies to RBC antigens are present in the
ponents into the venous circulation.
plasma; these antibodies are often called agglutinins. People
BLOOD GROUPS. Human blood is commonly classified into with blood group A have B antibodies (agglutinins); A antibod-
four main groups (A, B, AB, and O). The surface of an indi- ies are present in people with blood group B; and people with
viduals red blood cells contains a number of proteins known blood group O have antibodies to both A and B antigens. Peo-
ple with group AB blood do not have antibodies to either A or B
antigens (Table 5211). When blood is transfused, the blood
CULTURALLY COMPETENT CARE
Blood and Blood Products
TABLE 5211 The Blood Groups with Their
Jehovahs Witnesses do not receive blood or blood products. Constituent Agglutinogens and Agglutinins
Blood volume expanders are acceptable if they are not deriva-
tives of blood. BLOOD RBC ANTIGENS PLASMA ANTIBODIES
Christian Scientists do not ordinarily use blood or blood products. TYPES (AGGLUTINOGENS) (AGGLUTININS)
A A B
Note: From Transcultural Concepts in Nursing Care (4th ed.) (pp. 470, 481), by B B A
M. M. Andrews and J. S. Boyle, 2003, Philadelphia: Lippincott Williams & Wilkins. AB A and B
Reprinted with permission. O A and B
koz74686_ch52.qxd 11/8/06 2:08 PM Page 1473
group of the donor and recipient must match to avoid an anti- eliminated by a history of hepatitis, HIV infection (or risk fac-
gen-antibody reaction and destruction (hemolysis) of RBCs. tors for HIV infection), heart disease, most cancers, severe
asthma, bleeding disorders, or convulsions. Donation may be
RHESUS (RH) FACTOR. The Rh factor antigen is present on deferred for people with malaria or who have been exposed to
the RBCs of approximately 85% of the people in the United malaria or hepatitis or in situations of pregnancy, surgery, ane-
States. Blood that contains the Rh factor is known as Rh- mia, high or low blood pressure, and certain drugs.
positive (Rh); when it is not present the blood is said to be
Rh-negative (Rh). In contrast to the ABO blood groups, Rh BLOOD AND BLOOD PRODUCTS FOR TRANSFUSION. Most
blood does not naturally contain Rh antibodies. However, on clients do not require transfusion of whole blood. It is more com-
exposure to blood containing Rh factor (e.g., an Rh mother mon for clients to receive a transfusion of a particular blood com-
carrying a fetus with Rh blood, or transfusion of Rh blood ponent specific to their individual needs. Table 5212 lists some
into a client who is Rh), Rh antibodies develop. Subsequent of the common blood products that may be transfused.
exposures to Rh blood place the client at risk for an
TRANSFUSION REACTIONS. Transfusion of ABO- or Rh-
antigenantibody reaction and hemolysis of RBCs.
incompatible blood can result in a hemolytic transfusion reac-
BLOOD TYPING AND CROSSMATCHING. To avoid transfus- tion with destruction of the transfused RBCs and subsequent
ing incompatible red blood cells, both blood donor and recipi- risk of kidney damage or failure. Other forms of transfusion
ent are typed and their blood crossmatched. Blood typing is reaction also may occur, including febrile, allergic, circulatory
done to determine the ABO blood group and Rh factor status. overload, and sepsis. Because the risk of an adverse reaction
This test is also performed on pregnant women and neonates to is high when blood is transfused, clients must be frequently
assess for possible intrauterine exposure of either to an incom- and carefully assessed before and during transfusion. Many re-
patible blood type (particularly Rh factor incompatibilities). actions become evident within 5 to 15 minutes of initiating the
Because blood typing only determines the presence of the transfusion but they can develop any time during a transfu-
major ABO and Rh antigens, crossmatching also is necessary sion; clients are closely monitored during the initial period of
prior to transfusion to identify possible interactions of minor the transfusion. Stop the transfusion immediately if signs of a
antigens with their corresponding antibodies. RBCs from the reaction develop. Possible transfusion reactions, their clinical
donor blood are mixed with serum from the recipient; a reagent signs, and nursing implications are listed in Table 5213.
(Coombs serum) is added, and the mixture is examined for vis-
ADMINISTERING BLOOD. Special precautions are necessary
ible agglutination. If no antibodies to the donated RBCs are
present in the recipients serum, agglutination does not occur when administering blood.
and the risk of transfusion reaction is small. When a transfusion is ordered, obtain the blood from the blood
bank just before starting the transfusion. Do not store the blood in
SELECTION OF BLOOD DONORS. Screening of blood donors the refrigerator on the nursing unit; lack of temperature control
is rigorous. Criteria have been established to protect the donor may damage the blood. Once blood or a blood product is removed
from possible ill effects of donation and to protect the recipi- from the refrigerator, there is a limited amount of time to adminis-
ent from exposure to diseases transmitted through the blood. ter it (e.g., packed RBCs should not hang for more than 4 hours af-
Blood donors are unpaid volunteers. Potential donors are ter being removed from the refrigerator). Follow agency policies
for verifying that the unit is correct for the client. The U.S. Food tions should be administered with blood; they may cause the blood
and Drug Administration (FDA) requires blood products to have cells to clump or cause clotting. A transfusion should be completed
bar codes to allow for scanning and machine-readable information within 4 hours of initiation. The risk of sepsis increases if blood
on blood and blood component container labels to help reduce hangs for a longer period. Blood tubing is changed after every 4 to
medication errors (FDA, 2004). Blood is usually administered 6 units per agency policy; new intravenous tubing is used follow-
through a #18- to #20-gauge intravenous needle or catheter; using ing a transfusion.
a smaller needle may slow the infusion and damage blood cells (al-
though a smaller gauge needle may be necessary for small children CLINICAL ALERT
or clients with small, fragile veins). AY-type blood transfusion set
Normal saline should always be used when giving a blood transfusion.
with an in-line or add-on filter is used when administering blood If the client has an infusion of dextrose, stop that infusion and flush the
(Figure 52-30 ). One arm of the administration set connects to the line with saline prior to initiating the transfusion. Solutions other than
blood; normal saline (0.9% NaCl) is attached to the other arm of saline can cause damage to the blood components.
the Y-type set. Saline is used to prime the set and flush the needle
before administering blood. It also provides a means to keep the To initiate, maintain, and terminate a blood transfusion, see
vein open should a transfusion reaction occur. No other IV solu- Skill 52-6.
koz74686_ch52.qxd 11/8/06 2:08 PM Page 1475
To saline To
solution blood
Spikes
Upper
clamps
Drip chamber
Blood filter
chamber
Slide clamp
Y-Injection site
Adapter
fusion. son for the transfusion. For example, for an anemic client, note
Verify that a signed consent form was obtained. the hemoglobin and hematocrit levels.
Assess vital signs for baseline data, including blood pressure,
pulse, respiratory rate and depth, and temperature.
IV pole
Due to the need for sterile technique and technical complexity,
Venipuncture set containing a #18- to #20-gauge needle or
blood transfusion is not delegated to UAP. The nurse must en-
catheter (if one is not already in place) or, if blood is to be ad-
sure that the UAP knows what complications or adverse signs
ministered quickly, a larger catheter
can occur and should be reported to the nurse.
Chlorhexidine solution
Alcohol swabs
Equipment
Tape
Blood product
Clean gloves
Blood administration set
ister blood. The preferred needle size is from #18 to #20 not administer blood to a client without an arm band.
gauge, and the solution must be normal saline. Dextrose 3. Set up the infusion equipment.
(which causes lysis of RBCs), Ringers solution, medications Ensure that the blood filter inside the drip chamber is suit-
and other additives, and hyperalimentation solutions are in- able for whole blood or the blood components to be trans-
compatible. Refer to step 5 below if the infusing solution is fused. Attach the blood tubing to the blood filter, if necessary.
not compatible. Rationale: Blood filters have a surface area large enough to
If the client does not have an IV solution infusing, check allow the blood components through easily but are de-
agency policies. In some agencies an infusion must be run- signed to trap clots.
ning before the blood is obtained from the blood bank. In Put on gloves.
this case, you will need to perform a venipuncture on a suit- Close all clamps on the Y-set: the main flow rate clamp and
able vein (see Skill 52-1) and start an IV infusion of normal both Y-line clamps.
saline. Using a twisting motion, insert the piercing pin (spike) into a
SKILL 52-6
Invert the blood bag gently several times to mix the cells with
Y-set.
Open the clamp on the blood arm of the Y-set and prime the
tubing.
7. Establish the blood transfusion.
The blood will run into the saline-filled drip chamber. If nec-
8. Observe the client closely for the first 5 to 10 minutes. If no infusion is to follow, clamp the blood tubing and re-
Run the blood slowly for the first 15 minutes at 20 drops per
move the needle. If another transfusion is to follow, clamp
minute. the blood tubing and open the saline infusion arm. Blood ad-
Note adverse reactions, such as chilling, nausea, vomiting,
ministration sets are changed within 24 hours or after 4 to 6
skin rash, or tachycardia. Rationale: The earlier a transfusion units of blood per agency protocol.
If the primary IV is to be continued, flush the maintenance
reaction occurs, the more severe it tends to be. Identifying
such reactions promptly helps to minimize the conse- line with saline solution. Disconnect the blood tubing system
quences. and reestablish the intravenous infusion using new tubing.
Remind the client to call a nurse immediately if any unusual
Adjust the drip to the desired rate. Often a normal saline or
symptoms are felt during the transfusion. other solution is kept running in case of delayed reaction to
If any of these reactions occur, report these to the nurse in
the blood.
Discard the administration set according to agency practice.
charge and take appropriate nursing action (see Table 5213).
9. Document relevant data. Needles should be placed in a labeled, puncture-resistant
Record starting the blood, including vital signs, type of blood,
container designed for such disposal. Blood bags and ad-
blood unit number, sequence number (e.g., no. 1 of three ministration sets should be bagged and labeled before be-
ordered units), site of the venipuncture, size of the needle, ing sent for decontamination and processing. See agency
and drip rate. policy.
Remove gloves.
SAMPLE DOCUMENTATION Again monitor vital signs.
1/21/2008 1400 1 unit of PRBCs (#65234) hung to be in- 12. Follow agency protocol for appropriate disposition of the blood
fused over 3 hours. IV site in (L) forearm with 19 G an- bag.
On the requisition attached to the blood unit, fill in the time
giocath. VS taken (see transfusion record). Informed to the transfusion was completed and the amount transfused.
contact nurse if begins to experience any discomfort dur- Attach one copy of the requisition to the clients record and
ing transfusion. Stated he would use the call light. another to the empty blood bag.
____________________________C. Jones, RN. Return the blood bag and requisition to the blood bank.
EVALUATION
Evaluate the following:
Changes in vital signs or health status
Presence of chills, nausea, vomiting, or skin rash
Administer prescribed supplemental potassium (PO, NG, or IV) Low potassium levels are dangerous and Mrs. Chapman may
per policy. require supplements.
Monitor for neurologic and neuromuscular manifestations of hy- Potassium is a vital electrolyte for skeletal and smooth muscle
pokalemia (e.g., muscle weakness, lethargy, altered level of con- activity.
sciousness).
koz74686_ch52.qxd 11/8/06 2:08 PM Page 1479
Maintain accurate I & O record. Accurate records are critical in assessing the patients fluid balance.
Monitor vital signs as appropriate. Vital sign changes such as increased heart rate, decreased blood
pressure, and increased temperature indicate hypovolemia.
Give fluids as appropriate. As her nausea decreases encourage her oral intake of fluids as tol-
erated, again to replace lost volume.
Administer IV therapy as prescribed. Mrs. Chapman has signs of severe fluid volume deficit. She will
probably require intravenous replacement of fluid. This is especially
true because her oral intake is limited because of nausea and
vomiting.
EVALUATION
Outcomes met. Mrs. Chapman remained hospitalized for 48 hours. She required fluid replacement of a total of 5 liters. Her blood pressure
increased to 122/74, pulse rate decreased to a resting level of 74, and respirations decreased to 12/minute. Her urine output increased as
the fluid was replaced and was adequate at > 0.5 mL/kg/hour by the time of discharge. The urine specific gravity was 1.015. Lab work on
the day of discharge was: K: 3.8 and Na: 140. She had elastic skin turgor and moist mucous membranes. She was taking oral fluids and
was able to discuss symptoms of deficient fluid volume that would necessitate her calling her health care provider.
*
The NOC # for desired outcomes and the NIC # for nursing interventions and seleted activities are listed in brackets following the appropriate out-
come or intervention. Outcomes, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further
individualized for each client.
Sales clerk, Reports weakness, Height: 160 cm (5' 3") Urine specific gravity: 1.035
malaise, and flu-like symptoms for 3-4 Weight: 66.2 kg (146 lbs) Serum sodium: 155 mEq/L
MC days. Although thirsty, is unable to T: 38.6C; P: 96 BPM; Serum potassium 3.2 mEq/L
assess
27 y.o. female tolerate fluids because of nausea and R: 24; BP: 102/84 Chest x-ray negative
vomiting, and she has liquid stools 2-4 Dry mucous membranes
times per day. Decreased skin turgor
Deficient Fluid Volume r/t nausea, vomiting, diarrhea aeb decreased urine output, increased urine
concentration, weakness, fever, decreased skin turgor, dry mucous membranes, increased pulse,
and decreased BP
outcome
outcome
Outcomes met: Fluid balance aeb not
BP: 122/74 compromised
P: 74 24 hour intake and output
Urine output Blood pressure, pulse, Electrolyte and Acid/ Outcomes met:
evaluation Base Balance aeb
increased and temperature Serum potassium:
Specific gravity: Skin turgor not compromised evaluation 3.8 mEq/L
1.105 Urine specific gravity Serum electrolytes Serum sodium:
Moist mucous Mucous membranes Muscle strength 140 mEq/L
membranes
Elastic skin turgor
activity activity
activity
activity
Give activity
Monitor for
fluids as
Weigh neurologic and
appropriate Obtain specimens
daily and neuromuscular
Provide for analysis of
monitor manifestations
frequent altered potassium
trends activity of hypokalemia
oral levels as indicated
(e.g., hypotension,
hygiene tachycardia,
activity weak pulse, rhythm
activity irregularities)
CHAPTER 52 REVIEW
CHAPTER HIGHLIGHTS
A balance of fluids, electrolytes, acids, and bases in the body is Acidbase balance
necessary for health and life. is regulated by
The body fluid is divided into two major compartments: the buffers that neutralize
intracellular fluid (ICF) inside the cells and extracellular fluid (ECF) excess acids or bases; the
outside the cells. lungs, which eliminate or retain carbon dioxide, a potential acid;
Extracellular fluid is subdivided into two compartments: and the kidneys, which excrete or conserve bicarbonate and
intravascular (plasma) and interstitial. It constitutes about one- hydrogen ions.
fourth to one-third of total body fluid. Acidbase imbalance occurs when the normal 20-to-1 ratio of
ECF is in constant motion throughout the body. It is the transport bicarbonate to carbonic acid is upset. Imbalances may be either
system that carries nutrients to and waste products from the cells. respiratory or metabolic in origin; either can result in acidosis or
The percentage of total body fluids varies according to the alkalosis.
individuals age, body fat, and sex. The younger the person, the Factors that influence an individuals fluid, electrolyte, and
higher the proportion of water in the body. The less body fat acidbase balance include age, gender and body size,
present, the greater the proportion of body fluid. Postadolescent environmental temperature, and lifestyle. Illness, trauma, surgery,
females have a smaller percentage of fluid in relation to total body and certain medications can place individuals at risk for fluid,
weight than do men. electrolyte, and acidbase imbalances.
There are two types of body electrolytes (ions): positively charged Fluid, electrolyte, and acidbase imbalance is most accurately
ions (cations) and negatively charged ions (anions). determined through laboratory examination of blood plasma.
The principal ions of ECF are sodium and chloride; the principal Assessment relative to fluid, electrolyte, and acidbase balances
ions of ICF are potassium and phosphate. includes (a) a nursing history; (b) physical examination of the
Fluids and electrolytes move among the body compartments by skin, oral cavity, eyes, jugular vein, veins of the hand, and the
osmosis, diffusion, filtration, and active transport. neurologic system; (c) measurement of body weight, vital signs,
The major fluid pressures exerted as part of the movement of fluid and fluid intake and output; and (d) various diagnostic studies of
and electrolytes from one compartment to another are osmotic blood and urine.
pressure and hydrostatic pressure. A nursing history includes data about the clients fluid and food
The three sources of body fluid are fluids taken orally, food intake; fluid output; signs of fluid, electrolyte, and acidbase
ingested, and the oxidation of food. Fluid intake is regulated by the imbalances; and medications, therapies, or disease processes that
thirst mechanism. may disrupt these balances.
Fluid output occurs chiefly through excretion of urine, although body NANDA-approved nursing diagnoses that relate specifically to fluid,
fluid is also lost through sweat, feces, and insensible vapor loss. electrolyte, and acidbase imbalances include Deficient Fluid
In healthy adults, measurable fluid intake and output should Volume, Excess Fluid Volume, Risk for Imbalanced Fluid Volume,
balance (about 1,500 mL per day). The output of urine normally Risk for Deficient Fluid Volume, and Impaired Gas Exchange. Other
approximates the oral intake of fluids. Water from food and diagnoses that may be relevant are Impaired Oral Mucous
oxidation is balanced by fluid loss through the skin, respiratory Membrane, Impaired Skin Integrity, Decreased Cardiac Output,
process, and feces. Impaired Tissue Perfusion, Activity Intolerance, Risk for Injury, and
A number of body systems and organs are involved in regulating Acute Confusion.
the volume and composition of body fluids: the kidneys, the In many instances, fluids and electrolytes can be provided orally to
endocrine system, the cardiovascular system, the lungs, and the clients who are experiencing or at risk of developing fluid deficits.
gastrointestinal system. The kidneys are the primary regulator of The nurse needs to establish with the client a 24-hour plan for
fluid and electrolyte balance. ingesting the necessary fluids and to respect the clients fluid
Substances such as the antidiuretic hormone, the renin- preferences.
angiotensin-aldosterone system, and the atrial natriuretic factor are For clients with fluid retention, fluids may need to be restricted; a
also involved in maintaining fluid balance. schedule and short-term goals that make the fluid restriction more
Fluid imbalances include tolerable need to be developed.
a. Fluid volume deficit (FVD), also referred to as hypovolemia. For clients experiencing excessive fluid losses, the administration of
b. Fluid volume excess (FVE), also referred to as hypervolemia. fluids and electrolytes intravenously is necessary. Meticulous
c. Dehydration, a deficit in water and increase in serum aseptic technique is required when caring for clients with
sodium level. intravenous infusions.
d. Overhydration, an excess of water and decrease in serum Preventing complications such as infiltration, phlebitis,
sodium level. hypervolemia (circulatory overload), and infection is an important
The most common electrolyte imbalances are deficits or excesses aspect of intravenous therapy.
in sodium, potassium, and calcium. The administration of blood transfusions involves accurately
The acidbase balance (pH range) of body fluids is maintained matching and identifying the blood for the individual, correctly
within a precise range of 7.35 to 7.45. identifying the recipient, and monitoring the client throughout the
procedure for transfusion reactions.
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