FLUIDS AND ELECTORLYTE PHOSPHOLIPIDS

CELL -a type of lipid molecule that is the main

component of the cell membrane
-smallest autonomous functional unit of the
body PARTS:

CELL WALL HYDROPHILIC HEAD

-is a structural surrounding some types of cells,
just outside the cell membrane
Cell-> tissue-> organ
Endoplasmic reticulum
-lipids and protein synthesis
RIBOSOMES
-contains RNA and protein synthesis
NUCLEUS
-it contains DNA; it maintains integrity of the
cell by facilitates transcription
NUCLEULUS
-facilitate signal information, take the
responsibility of the stress
-retains water and adheres to the neighboring
cell
HYDROPHOBIC TAIL
-which expel water and can separate the
contents of the cell from the outside
environment
PROTEINS
-second major component of the cell
membrane where most of the functions of the
cellular membrane occur
-transport lipid-insoluble particles acting as
carriers to pass these compounds directly
through the membrane
CELL COAT

NUCLEAR MEMBRANE -long chains of complex carbohydrates make

up glycoproteins, glycolipids and lectins that
-it encloses cell nucleus that permits the form the outside surface of the cell
passage of proteins and foreign materials
-this intricate coat helps in cell-to-cell
GOLGI apparatus- recognition and adhesion
CYTOPLASM -also help replication in the cell
-give shape to the cell BODY FLUID COMPOSITION
MITOCHONDRIA WATER
-produces energy, ATP -primary component of body fluids
CHLOROPLAST Neonate- 80%
-where energy is process Infant-70%

Child -65%

Adult male-60%

Adult female-50%
FUNCTIONS: >can increase significantly during:

1. Temperature regulation -exercise -sweat

2. Transport of materials to/from the cells
-during illness-pt becomes tachypnic, GI
3. Aqueous medium for cellular
losses
metabolism (provides a medium for
metabolic reaction) -high environmental temperature
4. Assist in food digestion(hydrolysis)
5. Act as solvent in which solute are Approximate values of 24 hour fluid gain
available for cell function and loss of an adult
6. Maintain blood volume INTAKE GAIN
7. Medium of waste excretion
8. Cushion body parts for injury H2O(orally) 1,000

Water in food 1,300

FACTORS AFFECTING BODY WATER: Oxidation 200

1) AGE TOTAL: 2500ml

Infant 70-80%

Adult-50-60% OUTPUT(loss)

Elderly 45-50% Urine 1500

Feces 200

2.) SEX Perspiration 500

MALE-60% Respiration 300

Female-50% TOTAL 2500

3) BODY FATS

-Fat cells contains little H2O ELECTROLYTES

-obese->accumulated body fats->Contains -substances that dissociate in solution to

little water form charged particle called IONS

PS: Body water intake and output should CATION- positive charge ions
be the same ANION-Negative charge ions
Average 2500mL Milli equivalent per liter

4 MAJOR FUNCTION OF ELECTROLYTES

INSENSIBLE WATER LOSS 1. Water balance
>occurs through skin, lungs and feces 2. Enzyme reactions- body needs
electrolyte trough enzyme reaction
3. Acid-base balance-
 4. Neuromuscular activity- Potassium and
calcium. It regulates neuromuscular
activity
If sobra ang calcium-contractility of the
heart
If sobra magnesium- depressed deep
tendon reflex
MAJOR ELECTROLYTE PER BODY
COMPARTMENT
-ICF (anions) phosphate/ sulfates/ proteins
(CATIONS) potassium/ magnesium
-ECF(anions) chloride/ bicarbonate- most
abundant Chloride
(Cations) sodium/ calcium/magnesium-
most abundant is the sodium
If there is too much water in the cell because
of the sodium, there will be swelling
BODY FLUID COMPARTMENT(DISTRIBUTION)
- TOTAL BODY WATER is the
equivalent of the fluid that exist in
all the fluid compartments. This
approximately 60% of the body
weight of an average adult.
1. Intracellular fluid (ICF) (40%)
-make’s 40% of body weight
Rich in electrolytes, potassium,
magnesium, inorganic and organic
phosphates and proteins
2. EXTRACELLULAR FLUID (ECF) (20%)
- Accounts for 20% of the body
weight
- Rich in electrolytes: sodium,
chloride and bicarbonate
ECF is further classified by location:
A). INTERSTITIAL FLUID (15%)
- located in the spaces between most
cells of the body
- accounts for approximately 15% of
body weight
B.) INTRAVASCULAR FLUIDS (5%)
- blood vessels compartments
-called “plasma”
C.) TRANCELLULAR FLUID (1%)
- includes urine; digestive secretions;
perspiration; and cerebrospinal, pleural,
synovial, intraocular, gonadal, and
pericardial fluids
-the transcellular space contributes
approximately 1% of the body fluid, and
significant gains and losses do not occur
on a daily basis
MECHANISM OF FLUID TRANSPORT
1. ACTIVE TRANSPORT
- Active transport allows molecules to
move across cell membranes and
epithelial membranes against a
concentration gradient
-solutes move from an area of lower
concentration to higher concentration
TYPES OF ACTIVE TRANSPORT:
1. Primary active transport- uses the initial
source of energy to carry substance
2. Secondary active transport
(cotransport)- harnesses the energy
obtained from the primary active
 transport and uses it as a cotransporter
of a secondary substance
3 KINDS OF ENDOCYTOSIS
-facilitate the transport of substance
a. Phagocytosis or cellular eating- WBC
gulp bacteria thingy
b. Pinocytosis or cellular drinking – occur
in the MIRCO VILLI IN THE INTESTINE
c. Receptor –mediated endocytosis- binds
to receptor (LBL) to facilitate active
transport
Ex. Glucose needs insulin to go to the
cell.
EXOCYTOSIS
-manufactured substance that pass in the
secretory vesicle outside of the cell (release)
PASSIVE TRANSPORT
- this process is carried out to maintain the
balance and equilibrium of the cell
OSMOSIS
-is the process by which water moves across a
selectively permeable membrane from an area
of lower solute concentration to an area of
higher solute concentration
-primary process that controls body fluids
movement between the ICF and ECF
compartments
-IT IS THE WATER THAT MOVES
RELATED TERMS
OSMOLALITY- Concentration of a solution
Milli osmols per kg
Normal:280-300 milli osmols per kg
OSMOLARITY – the number of solutes per liter
of a fluid
OSMOTIC PRESSURE- the power of a solution to
draw water across a membrane
ONCOTIC PRESSURE- osmotic pressure exerted
by plasma proteins in the vessels
Normal: 28 mmhg
Colloid osmotic pressure
TONICITY
-refers to the effect a solution’s osmotic
pressure has on water movement across the cell
membrane of cells within that solution
ISOTONIC- no significant changes inside the
cells; equal amount of the water transported to
the cell
Ex. PLAIN LR
HYPERTONIC- more solutes in the cell than the
plasma; water drawn out to the cell causes
SHRINKAGE OF THE CELL
Ex. Solutions that contains 5% of solution, D5LR,
D5water, 0.9NaCl
HYPOTONIC SOLUTION- has lower solute
concentration then the plasma: water is
transported to the cell; it will cause swelling of
the cell
DIFFUSION
-it is the process by which solute molecules
move from and area of high solute
concentration to an area of low solute
concentration to become evenly distributed.
-IT IS THE SOLUTE THAT MOVES
TYPES:
Simple diffusion –random movement
Ex. Occurs inside the lungs; oxygen and carbon
dioxide
Facilitated diffusion – carrier mediated; need
one molecule to facilitate past through from
one gradient to another
FILTRATION
-the process by which water and dissolved
substances (solutes) move from an area of high
hydrostatic pressure to an area of low
hydrostatic pressure
-FILTRATION HAPPENS IN GLUMEROLOUS
HYDROSTATIC PRESSURE
-created by the pumping action of the heart and
gravity against the capillary wall
OCTOBER 12,2020
FLUID REGULATION
 Water level drop (anoreua, nausea
happens) > hypothalamus creates
feelings of thirst> posterior pituitary
releases more ADH> the person drinks
water. ADH stimulates kidneys to
reabsorb more water > homeostasis
(water level in blood)
 Water level rises above normal range>
hypothalamus defects low solute
concentration> pituitary releases less
ADH> kidney reabsorbs less water>
homeostasis and vice versa
Fluid regulation system
1. Thirst
- Consider primary regulator of water
intake
- Plays an important role in
maintaining fluid balance and
preventing dehydration
2. Kidneys
- Are primary responsible for
regulating fluid volume and
electrolyte balance in the body
- They regulate the volume and
osmolality of body fluids by
controlling and excretion of water
and electrolyte
Major function of kidneys in
maintaining normal fluid balance
1. Regulate ECF volume and
osmolality
2. Regulation of electrolyte levels
in the ECF
3. Regulate ph of ECF by retention
of hydrogen ions
4. Excretion of metabolic wastes
and toxic substances
PS: PLASMA 170 L
99% back to the body; 1% to urine thingy
3. Respiratory system
- The lungs participate in the
maintenance of fluid balance by
excreting moisture during
exhalation
- Play a role in acid-base balance by
regulating excretion of carbon
dioxide
4. Renin-Angiotensin-Aldosterone system
(RAAS)
- Hormone system that regulates BP
and electrolyte balance and
systemic vascularity
- Decrease in blood pressure and
fluid volume> kidney is stimulated
 to release enzyme (renin) >to
stimulate the liver to release
angiotensinogen>renin acts on
angiotensin to form angiotensin 1>
Ace acts on angiotensin 1 to form
angiotensin II> angiotensin II acts
on the adrenal gland to stimulate
release of aldosterone
- Organs include in RAAS (kidneys,
liver, lungs and aldosterone)
PS. Angiotensin II act directly to blood vessel.
Stimulating in vasoconstriction
(narrowing)>there will be more blood to
compensate.
PPSS. Aldosterone acts on the kidney to
stimulate reabsorption of SALT (NaCl) and water
5. Antidiuretic hormone (vasopressin)
- Regulates water
- Low BP& blood volume / High
blood osmolality > osmoreceptors
in hypothalamus stimulate
posterior pituitary to secrete ADH
> ADH increase distal tubule
permeability to More reabsorption
of H20> decrease urine
output>increase blood
pressure>increase blood volume>
decrease blood osmolality
6. Atrial Natriuretic peptide (ANP)
- Releases by heart if the heart
muscle is stretched
- Increase blood volume causes
increase atrial stretch>atrial
myocardial cells stretch and
release> Atrial natriuretic peptide>
a. Hypothalamus> inhibits
vasopression> NaCl and H20
excretion
b. Kidney> Increase of glomerular
filtration rate and decrease
renin> NaCl and H20 excretion
c. Adrenal cortex>inhibits
aldosterone> NaCl and H20
excretion
d. Medulla oblongata> decreases
blood pressure
7. Cortisol
- Steroid hormone
- Most bodily cells have cortisol
- Control the blood pressure, blood
sugar level and metabolism
- Increase GFR renal plasma flow>
increase phosphate excretion,
increase Na, H20 retention and
Potassium retention
- PARATHYROID HORMONE
 Most important
endocrine regulator of
calcium and
phosphorus
concentration in
extracellular fluid
FLUID SHIFTS
Osmotic forces
- the principal determinant of water
distribution in the body
osmotic pressure
- is actually determined by the
movement or draw of water
through a selectively permeable
membrane toward an area of
greater solute concentration
osmolality
- number of osmoles of a substance
contained within a kilogram of
water
osmole e.g. excessive administration of hypertonic
solution
- number of molecules in 1g
molecular weight of undissociated
solute
FLUID VOLUME IMPAIRMENT

2 types
Movements of fluids at the capillary membrane
a. Fluid volume deficit
FLUID SHIFS b. Fluid volume excess

- PLASMA TO INTERSTITILA
- INSTERTITIAL TO PLASMA
FLUID VOLUME DEFICIT
EDEMA – palpable swelling produced by
- Is a decrease in intravascular,
expansion of the interstitial fluid volume
interstitial, and/or intracellular fluid
- Third spacing is a shift of fluid from in the body.
the vascular space into an area
Causes:
where it is not available to support
normal physiologic processes - Excessive fluid losses
- Insufficient fluid intake
- Failure of regulatory mechanisms
4 major causes of edematous state - Fluid shifts within the body

1. Decrease colloid osmotic pressure in Classification:

the capillary
- E.g. burns, liver failure
2. Increased capillary hydrostatic pressure
- E.g. Congestive heart failure
3. Increased capillary permeability
- e.g. Burns, allergic reactions
4. Lymphatic obstruction or increase
interstitial colloid osmotic pressure
- E.g. Surgical removal of lymph
structures
Isoosmolar fluid volume deficit
- Occurs when sodium and water are
lost in equal amounts
Hyperosmolar fluid volume deficit
- Occurs when more fluid is lost than
sodium
Hypoosmolar fluid volume deficit

MANAGEMENT FOR EDEMA - Occurs when electrolyte loss is

greater than fluid
- Diuretic therapy
- Elevating the affected extremity ETIOLOGIC
- Elastic support stockings in the a. Excessive loss of GI fluid ex. Vomiting,
morning diarrhea
- Albumin IV b. Diuretics
B. INTERSTITIAL TO PLASMA c. Renal disorder
d. Endocrine disorder
- Movement back of edema to circulatory e. Excessive exercise
volume
 f. Hot environment - The CVP catheter is an important
g. Hemorrhage tool used to assess right ventricular
h. Chronic abuse of laxatives function normal CVP is 2-6mm Hg
i. Inadequate fluid intake - CVP is elevated by: over hydration
which increases venous return
ECF FLUID LOSS>fluid shifts form interstitial to
heart failure or PA stenosis which
intravascular to restore vascular volume &
limit venous outflow and lead to
hypernatremic state
venous congestion
- Positive pressure breathing,
straining
a. ADH/ aldosterone - CVP decrease with:
b. Fluids are reabsorbed form the Colom a. Hypovolemic shock form
c. Inc. vasoconstriction hemorrhage, fluid shift,
d. Stimulation of thirst mechanism dehydration
Manifestation b. Negative pressure breathing
which occurs when the patient
- Rapid weight loss negative pressure which is
Fluid loss percentage of body sometimes used for high spinal
weight: cord injuries
2% mild FVD
5% moderate Medical management
8% or greater severe 1. Fluid restoration
- Postural or hypostatic hypotension a. Oral rehydration
- Flat neck veins b. IV rehydration
- Tachycardia, pale, cool skin - Isotonic ECFVD is treated with
- Decrease urine output isotonic solution
Diagnostic - Hypertonic ECFVD is treated with
hypotonic solution
- Serum electrolytes= in an isotonic - Hypotonic ECFVD is treated with
deficit sodium levels are within hypertonic solution
normal limits; when the loss is 2. Monitor for complications of
water only, sodium levels are high. fluid restoration
Decreases in potassium are 3. Correction of underlying
common problem
- Ser
NURSING MANAGEMENT

1. VS every 2-4 hrs., report changes form

CENTRAL VENOUS PRESSURE
- Is the blood pressure in the venae
cavae, near the right atrium of the
heart. CVP reflects the amount of
blood returning to the heart and
the ability of the heart to pump the
blood back into the arterial system
baseline VS; assess CVP every 4hrs (if
patient has CVP access)
2. I&O every 8 hours or hourly
3. Administer IV fluids as prescribed using
an infusion pump. Monitor for
indicators of fluid overload if rapid fluid
replacement is ordered: dyspnea,
 tachypnea, tachycardia, increase CVP, Indications for intravenous therapy
jugular vein distention, and edema
1. patients can receive life- sustaining
4. Weight patient daily and record
fluids, electrolytes, and nutrition
5. Monitor laboratory values: electrolytes,
when they are unable to eat or
serum osmolality, blood urea nitrogen
drink adequate amounts.
(BUN), and hematocrit
2. The IV route also allows rapid
6. Monitor for changer=s in level of
delivery of medication in an
consciousness and mental status.
emergency
7. Institute safety precautions
3. Patients with anemia or blood loss
8. Teach patient and family members how
can receive lifesaving IV transfusion
to reduce orthostatic hypotension
4. Patients who are unable to eat for
NSG DIAGNOSIS an extended period can have their
nutritional needs met with total
1. Fluid volume deficit
parenteral nutrition (TPN)
- Patients with a fluid volume deficit
due to abnormal losses, inadequate TYPE OF INFUSIONS
intake, or impaired fluid regulation
1. Continues infusion
require close monitor
- In a continues infusion, the
2. Ineffective tissue perfusion
physician orders the infusion in
- A fluid volume deficit can lead to
milliliters (mL) to be delivered over
decreased perfusion or renal,
a specific amount of time; for
cerebral, and peripheral tissues.
example, 100 mL
Inadequate renal perfusion can lead
to acute failure. Decreased cerebral
perfusion leads changes in mental
and cognitive function causing 2. Intermittent infusion
restlessness, anxiety, agitation, - Intermittent IV lines are “capped
excitability, confusion, vertigo, off” with an injection port used only
fainting and weakness. periodically. Thus intermittent IV
3. Risk for injury therapy is administered at
- The patient with fluid volume deficit prescribed intervals. You must
is at risk for injury because of ensure that an intermittent
dizziness and loss of balance catheter
resulting from decreased cerebral 3. Bolus
perfusion secondary to - A bolus drug (sometimes called an
hypovolemia. IV push or IVP drug) is injected
- slowly via a syringe into the IV site
or tubing port.
IV THERAPY 4. Piggy back/ secondary infusion
- Some IV medications, such as
- IV therapy is the administration of
antibiotics, need to be infused over
fluid or medication via a needle or
a short period of time. For example,
catheter (sometime called a
an antibiotic may be mixed with 50
cannula) directly into the
mL of dextrose solution and infused
bloodstream
over 30 minutes. If the patient
 already has a primary continuous IV
infusing, the antibiotic (secondary)
infusion can be “piggybacked” into
the primary IV line. In order for the
piggyback medication to infuse, it
must hang higher than the primary
infusion. Piggyback medications can
be infused using either gravity or a
controller. The medication in the
piggyback must be compatible with
any other solution that is in the
primary IV tubing.
Methods of infusion
1. Gravity drip
2. Electronic control devices
A. Gravity drip
Types of IVF solutions
Factors affecting flow rates
a. Change in catheter position
- A change in the catheter’s position
may push the bevel either against
the wall of the vein, which will
decrease the flow rate, or away
from the wall of the vein, which
may increase the flow rate.
- Careful taping and avoidance of
joint flexion above the site
minimizes this problem. Patients
may need to be reminded to keep
flexion to a minimum when an IV is
placed near a joint.
b. Height of the solution
- Because infusions flow by gravity, a
change in the height of the infusion
bag or bottle or a change in the
level of the bed can increase or
decrease the flow rate. The flow
rate increases as the distance
between the solution and the
patient increases. A patient may
alter the flow rate greatly simply by
standing up. The ideal height for a
solution is 3 feet above the level of
the heart.
c. Patency of the catheter
- Never exert pressure with a saline
or heparin flush in an attempt to
restore patency; doing so may
dislodge a clot into the vascular
system or rupture the catheter
A. Electronic control devices
- Electronic pumps and controllers
regulate the rate of infusion
2 types of IVFs, crystalloid and colloid
solutions
1. Colloids
- Fluids that expand the circulatory
volume due to particles that cannot
cross a semipermeable membrane.
They pull fluid from the interstitial
space into the intravascular space,
increasing fluid volume. This can be
a great advantage in cases of large
losses of fluid, such as severe
trauma and haemorrhage. The main
disadvantage are cost and the risk
of volume overload, including
pulmonary edema.
- Types of colloids are dextrans and
hetastarches
2. crystalloids
- work much like colloids but do not
stay in the intravascular circulation
as well as colloids do
- cheaper and are more convenient
to use
 - primary fluid for IV therapy
containing electrolytes but lacks
large protein molecules
- They provide hydration and calories
to patients and include dextrose,
normal saline, and Ringer’s and
lactated Ringer’s solution.
2 IVF classification
- according to tonicity and according
to purpose
TONICITY
Tonicity of IV Solutions
 Intravenous fluids may be classified as
isotonic, hypotonic, or hypertonic.
 Isotonic fluids have the same
concentration of solutes to water as
body fluids. Hypertonic solutions have
more solutes (i.e., are more
concentrated) than body fluids.
Hypotonic solutions have fewer solutes
(i.e., are less concentrated) than body
fluids. Water moves from areas of
lesser concentration to areas of greater
concentration.
 Therefore, hypotonic solutions send
water into areas of greater
concentration (cells), and hypertonic
solutions pull water from the more
highly concentrated cells.
1. isotonic solutions
- Normal saline (0.9% sodium
chloride) solution is an isotonic
solution that has the same tonicity
as body fluid. When administered
to a patient requiring water, it
neither enters cells nor pulls water
from cells; it therefore expands the
extracellular fluid volume.
- A solution of 5% dextrose in water
(D5W) is also isotonic when infused,
but the dextrose is quickly
metabolized, making the solution
hypotonic.
2. Hypotonic Solutions
- Hypotonic fluids are used when
fluid is needed to enter the
cells, as in the patient with
cellular dehydration. They are
also used as fluid maintenance
therapy.
- An example of a hypotonic
solution is 0.45% sodium
chloride solution.
3. Hypertonic Solutions
- Examples of hypertonic
solutions include 5% dextrose in
0.9% sodium chloride and 5%
dextrose in lactated Ringer’s
solution.
- Hypertonic solutions are used
to expand the plasma volume,
as in the hypovolemic patient.
They are also used to replace
electrolytes.
ACCORDING TO PURPOSE
1) Hydrating
 Replace water loss
 Dilute meds
 Keep veins open
2) Nutritional
 Promotes faster recuperation
3) Maintenance
 Replace electrolyte loss at ECF level
 Maintenance in patients with no oral
intake
 Replace fluid loss
 Treatment for dehydration
4) Volume expander
 Increase osmotic pressure thus
maintain circulatory volume
 Table 2-3 Complications Of Peripheral Iv Therapy
Local Complications of IV Signs and Symptoms Nursing Interventions
Therapy
Hematoma Ecchymoses Remove catheter
Swelling Apply pressure with 2x2
Inability to advance catheter Elevate extremity
Resistance during flushing
Thrombosis Slowed or stopped infusion Discontinue catheter
Fever/malaise Apply cold compress to site
Inability to flush catheter Assess for circulatory
impairment
Phlebitis Redness at site Discontinue catheter
Site warm to touch Apply cold compress initially;
Local swelling then warm
Pain Consult physician if severe
Palpable cord
Sluggish infusion rate
Infiltration Coolness of skin at site Discontinue catheter
(Extravasation) Taut skin Apply cool compress
Dependent edema Elevate extremity slightly
Backflow of blood absent Follow extravasation
Infusion rate slowing guidelines
Have antidote available
Local Infection Redness and swelling at site Discontinue catheter and
Possible exudate culture
Increase WBC count site and catheter Apply
Elevated T lymphocytes sterile dressing over
site
Administer antibiotics if
ordered
Venous Spasm Sharp pain at site Apply warm compress to site
Slowing of infusion Restart infusion in new site if
spasm continues
Table 2-4 Systemic Complication of Peripheral IV Therapy

Complication Signs and Symptoms Nursing Interventions

Septicemia Fluctuating temperature Restart new IV system
Profuse sweating Obtain cultures
Nausea/vomiting Notify physician
Diarrhea Initiate antimicrobial
Abdominal pain therapy as ordered
Tachycardia Monitor patient closely
Hypotension
Altered mental status
Fluid Overload Weight gain Decrease IV flow rate
Puffy eyelids Place patient in high Fowler’s
Edema position
Hypertension Keep patient warm
Changes in input and output Monitor vital signs
(I&O) Administer oxygen Use
Rise in central venous microdrip set or
pressure (CVP) controller
Shortness of breath
Crackles in lungs
Distended neck veins
Air Embolism Lightheadedness Call for help!
Dyspnea, cyanosis, Place patient in
tachypnea, expiratory Trendelenburg’s position
wheezes, cough chest Administer oxygen
pain,hypotension Monitor vital signs
Changes in mental Notify physician
status
Coma

ALTERNATIVE ACCESS ROUTES These devices can have one, two, or

Central Venous Catheters
Central venous catheters terminate in
the superior vena cava near the heart. They are
used when peripheral sites are inadequate or
when large amounts of fluid or irritating
medication must be given. Central catheter
devices include a percutaneous catheter,
peripherally inserted central catheter (PICC),
tunneled catheter, and implanted port.
three lumens in the catheter or one or more
port chambers. Each lumen exits the site in a
separate line, called a tail. Multilumen catheters
allow for the administration of incompatible
solutions at the same time. Be careful not to
confuse a central catheter with a dialysis
catheter. Dialysis catheters should be used only
for dialysis and not for IV therapy, and should
be accessed only by physicians or specially
trained dialysis nurses.
 1) Percutaneous Central
Catheter
A percutaneous central catheter is
inserted by a physician into the jugular or
subclavian vein. After insertion, correct
placement is determined by x-ray before the
catheter is used.
These short-term central venous
catheters may remain in place up to several
weeks, but usual placement time is 7 days.
These catheters are inserted at the bedside and
are cost effective for short-term central venous
access in the acute care setting.
2) Peripherally Inserted
Central Catheter (PICC)
A PICC line is a long catheter that is
inserted in the arm and terminates in
the central circulation. This device is
used when therapy will last more than 2 weeks
or the medication is too caustic for peripheral
administration.
3) Tunneled Catheters
Central venous tunneled catheters
(CVTCs) are intended for use for months to
years to provide long-term venous access.
CVTCs are composed of polymeric silicone with
a Dacron polyester cuff that anchors the
catheter in place subcutaneously. The catheter
tip is placed in the superior vena cava.
4) Ports
A port is a reservoir that is surgically
implanted into a pocket created under the skin,
usually in the upper chest. An attached catheter
is tunneled under the skin into a central vein. An
advantage of a port is that, when not in use, it
can be flushed and left unused for long periods.
Ports can be used to administer
chemotherapeutic agents and antibiotics that
are toxic to tissues and are suitable for long-
term therapy. Ports should be accessed only by
specially trained RNs. Most ports require the
use of special noncoring needles that are
specifically designed for this purpose.
A) FLUID VOLUME
EXCESS
Fluid volume excess results when both water
and sodium are retained in the body. Fluid
volume excess may be caused by fluid overload
(excess water and sodium intake) or by
impairment of the mechanisms that maintain
homeostasis. The excess fluid can lead to excess
(1) intravascular fluid (hypervolemia) and (2)
excess interstitial fluid (edema).
ETIOLOGY
Fluid volume excess usually results from
conditions that cause retention of both
sodium and water. These
conditions include heart failure, cirrhosis of the
liver, renal failure, adrenal gland disorders,
corticosteroid administration, and stress
conditions causing the release of ADH and
aldosterone. Other causes include an excessive
intake of sodium-containing foods, drugs that
cause sodium retention, and the administration
of excess amounts of sodium-containing IV
fluids (such as 0.9% NaCl or Ringer’s solution).
This iatrogenic (induced by the effects of
treatment) cause of fluid volume excess
primarily affects patients with impaired
regulatory mechanisms.
PATHOPHYSIOLOGY
In fluid volume excess, the extracellular
compartment is expanded. This increase in
volume increases the pressure in the
vasculature. Baroreceptors sense the increase in
pressure and increase in their firing to the
central nervous system (CNS). In response, the
SNS is inhibited, and RAAS functions declines.
The resulting vasodilation promotes pooling of
blood and lowering of blood pressure.
Reabsorption of sodium in the renal tubules is
reduced, and more urine is excreted.
MANIFESTATIONS
Excess extracellular fluid leads to
hypervolemia and circulatory overload. Excess
fluid in the interstitial space causes peripheral
or generalized edema. The manifestations of
fluid volume excess relate to both the excess
fluid and its effects on circulation.
 Peripheral edema, or if severe, anasarca
(severe generalized edema)
 Full bounding pulse, distended neck and
peripheral veins, increased central
venous pressure, cough, dyspnea
(labored or difficulty breathing),
orthopnea (difficult breathing when
supine)  Dyspnea at rest
 Tachycardia and hypertension
 Reduced oxygen saturation
 Moist crackles on auscultation of the
lungs, pulmonary edema
 Increased urine output (polyuria)
 Ascites (excess fluid in the peritoneal
cavity)
 Decreased hematocrit and BUN
 Altered mental status and anxiety
 Pulmonary edema
Fluid overload can occur in either the
extracellular or intracellular
compartments of the body.
1) EXTRACELLULAR
FLUID OVERLOAD
 Occurs in either the intravascular
compartment or in the interstitial area
EDEMA- most common term associated
with fluid overload found in the
interstitial or lung tissue
HYPERVOLEMIA- when an
overabundance of fluid occurs in the
intravascular compartment
ISOTONIC FLUID VOLUME
EXCESS- type of fluid overload
wherein sodium and water remain
in equal proportions with each
other. Also results from a decreased
elimination of sodium and water.
ANASARCA- generalized edema
CAUSES OF
EXTRACELLULAR
FLUID OVERLOAD
 Excessive sodium intake through diet
 administration of hypertonic fluids
 D545 normal saline solution
 D5.9 normal saline solution
 10% Dextrose
 3% normal saline solution
 Diabetes insipidus
 Congestive heart failure
 Cirrhosis
 Renal failure
 Cushing’s syndrome
  Hyperaldosteronism  Anxiety
 Muscle weakness
MANIFESTATIONS OF  Twitching
EXTRACELLULAR FLUID OVERLOAD  Respiratory
 Pitting peripheral edema  Dyspnea on exertion
 Periorbital edema  Increased respirations
 Shortness of breath  Gastrointestinal
 Shift of interstitial fluid to plasma  Nausea and vomiting
 Bounding pulse and jugular venous  Increased thirst
distention  Cardiac
 Anasarca • Elevated blood pressure
 Rapid weight gain • Decreased pulse
 Moist crackles
 Tachycardia
 Hypertension DIAGNOSTICS
2) INTRACELLULAR FLUID
OVERLOAD 1) Serum electrolytes and serum osmolality
 also known as water intoxication are measured, but usually remain within
 Hypotonic fluid from the intravascular normal limits.
space moves by osmosis to an area 2) Serum hematocrit and hemoglobin often
of higher solute concentration inside are decreased due to plasma dilution
the cell. Cells run the risk of from excess extracellular fluid.
rupturing if they become too
overloaded with fluid. 3) Additional tests of renal and liver
function (such as serum creatinine, BUN,
CAUSES OF and liver enzymes) may be ordered to
INTRACELLULAR FLUID help determine the cause of fluid volume
OVERLOAD excess.
 Hypotonic intravenous administration
4) Chest radiograph- to check for presence
 0.45% normal saline solution
 5% dextrose in water of pulmonary congestion
 Excessive nasogastric tube irrigation 5) ABG- fluid in the alveoli impairs gas
with free water exchange resulting in hypoxia as
 Excessive administration of free evidenced by a low PO2
water via enteral tube feedings
 Syndrome of inappropriate
antidiuretic hormone
 Psychogenic polydipsia MEDICAL MANAGEMENT
Managing fluid volume excess focuses on
prevention in patients at risk, treating its
MANIFESTATIONS OF manifestations, and correcting the
INTRACELLULAR FLUID underlying cause.
OVERLOAD
 Neurological 1) DIURETICS
 Cerebral edema  Commonly used to treat fluid volume
 Headache excess. They inhibit sodium and
 Irritability water reabsorption, increasing urine
 Confusion output.
  The three major classes of diuretics,
each of which acts on a different part
of the kidney tubule, are as follows:
a) Loop diuretics
 Inhibit sodium and chloride
reabsorption in the ascending loop of
Henle
 Furosemide
 Ethacrynic acid
 Bumetanide
 torsemide
a) Thiazide-type diuretics
 Promote the excretion of sodium,
chloride, potassium and water by
decreasing absorption in the distal
tubule
 Bendroflumethiazide
 Chlorothiazide
 Hydrochlorothiazide
 Metolazone
 Polythiazide
 Chlorthalidone
 Trichlormethiazide
 Indamide
 Xipamid
a) Potassium-sparing diuretics
 Promote excretion of sodium and
water by inhibiting sodium-potassium
exchange in the distal tubule 
Spironolactone
 Amioride
 Triamterene
2) FLUID MANAGEMENT
 Fluid intake may be restricted in
patients who have fluid volume
excess. The amount of fluid allowed
per day is prescribed by the primary
care provider. All fluid intake must be
calculated, including meals and that
used to administer medications orally
or IV.
3) DIETARY MANAGEMENT
 Because sodium retention is a
primary cause of fluid volume
excess, a sodium-restricted diet
often is prescribed. The primary
dietary sources of sodium are the
salt shaker, processed foods, and
foods themselves.
NURSING MANAGEMENT
Nursing care focuses on preventing
fluid volume excess in patients at risk and
on managing problems resulting from its
effects.
1. Closely monitor for the vital signs
including heart sounds every 2-
4hours or as frequent as necessary.
® Hypervolemia can cause
hypertension, bounding peripheral
pulses, and a third heart sound (S3)
due to the volume of blood flow
through the hearts.
2. Auscultate lungs for presence or
worsening of crackles and wheezes;
auscultate heart for extra heart
sounds.
® Crackles and wheezes indicate
pulmonary congestion and edema. A
gallop rhythm (S3) may indicate
diastolic overloading of the
ventricles secondary to fluid volume
excess.
3. Place in Fowler’s position if dyspnea
or orthopnea is present.
® Fowler’s position improves lung
expansion by decreasing the
pressure of abdominal contents on
the diaphragm.
4. Monitor oxygen saturation levels and
arterial blood gases (ABGs) for
evidence of impaired gas exchange
(SaO2 < 92% to 95%; PaO2 < 80
mmHg). Administer oxygen as
indicated.
® Edema of interstitial lung tissues
can interfere with gas exchange and
delivery to body tissues.
Supplemental oxygen promotes gas
 exchange across the alveolar-
capillary membrane, improving
tissue oxygenation.
5. Assess for the presence and extent
of edema, particularly in the lower
extremities and the back, sacral, and
periorbital areas.
® Initially, edema affects the
dependent portions of the body—the
lower extremities of ambulatory
patients and the sacrum in
bedridden patients. Periorbital
edema indicates more generalized
edema.
6. Obtain daily weights at the same
time of day, using approximately the
same clothing and a balanced scale.
® Daily weights are one of the most
important gauges of fluid balance.
Acute weight gain or loss represents
fluid gain or loss. Weight gain of 2.2
lbs is equivalent to 1 L of fluid gain.
7. Administer oral fluids cautiously,
adhering to any prescribed fluid
restriction. Discuss the restriction
with the patient and significant
others, including the total volume
allowed, the rationale, and the
importance of reporting all fluid
taken.
® All sources of fluid intake,
including ice chips, are recorded to
avoid excess fluid intake
8. Provide oral hygiene at least every 2
hours. Oral hygiene contributes to
patient comfort and keeps mucous
membranes intact; it also helps
relieve thirst if fluids are restricted.
® Oral hygiene contributes to patient
comfort and keeps mucous
membranes intact; it also helps
relieve thirst if fluids are restricted.
9. Teach patient and significant others
about the sodium-restricted diet.
® Excess sodium promotes water
retention; a sodium-restricted diet is
ordered to reduce water gain.
Reducing sodium intake will help the
body excrete excess sodium and
water.
10. Administer prescribed diuretics as
ordered, monitoring the patient’s
response to therapy.
® Loop or high-ceiling diuretics such
as furosemide can lead to rapid fluid
loss and manifestations of
hypovolemia and electrolyte
imbalance.
NURSING DIAGNOSIS
1) Fluid Volume Excess
Nursing care for the patient with
excess fluid volume includes collaborative
interventions such as administering diuretics
and maintaining a fluid restriction, as well as
monitoring the status and effects of the
excess fluid volume.
2) Risk for Impaired Skin Integrity
Tissue edema decreases oxygen
and nutrient delivery to the skin and
subcutaneous tissues, increasing
the risk of injury.
3) Impaired Gas Exchange
With fluid volume excess, gas
exchange may be impaired by edema of
pulmonary interstitial tissues. Acute
pulmonary edema is a serious and
potentially life-threatening complication of
pulmonary congestion.