FUNDAMENTALS OF NURSING

Week 12: Fluid, Electrolyte and Acid-Base Balance

I. Body Fluids and Electrolytes - approximately 60% of the average healthy adult’s weight is
water, the primary body fluid.
A. Distribution of Body Fluids
1. Intracellular fluid (ICF) - within the cells of the body, two-thirds of the total
body fluid in adults
2. Extracellular fluid (ECF) - outside the cells, one third of the total body fluid
in adults
a) Intravascular fluid or plasma - within the vascular system, 20% of
ECF
b) Interstitial fluid - surrounds the cells, 75% of ECF
c) Lymph and transcellular fluids - remaining 5% of ECF
B. Composition of Body Fluid
1. Cations - charged particles or ions that carry a positive charge
2. Anions - charged particles or ions that carry a negative charge
C. Movement of Body Fluids and Electrolytes
1. Solutes - substances dissolved in a liquid
2. Crystalloids - salts that dissolve readily into true solutions
3. Colloids - substances such as large protein molecules that do not readily
dissolve into true solutions
4. Solvent - the component of a solution that can dissolve a solute
5. Osmolality - the total solute concentration within a fluid compartment and
is measured as parts of solute per kilogram of water
6. Isotonic solution - has the same osmolality as ECF
7. Hypertonic solution - have a higher osmolality than ECF
8. Hypotonic solution - have a lower osmolality than ECF
9. Osmotic pressure - the power of a solution to pull water across a
semipermeable membrane
10. Oncotic pressure - the power of plasma proteins to pull water from the
interstitial space into the vascular compartment
11. Diffusion - molecules move from a solution of higher concentration to a
solution of lower concentration
12. Osmosis - water moves across cell membranes, from the less
concentrated solution to the more concentrated solution
13. Filtration - fluid and solutes move together across a membrane from an
area of higher pressure to an area of lower pressure
14. Active transport - movement of solutes across cell membranes from a
less concentrated solution to a more concentrated one
D. Regulating Body Fluids
1. Fluid Intake - the thirst mechanism is the primary regulator of fluid intake
2. Fluid Output - via urine, feces or insensible losses
3. Maintaining Homeostasis - via the Renin-Angiotensin-Aldosterone System
E. Regulating Electrolytes
1. Sodium - 135-145 mEq/L; found in high levels in foods such as bacon,
 ham, processed cheese, and table salt
2. Potassium - 3.5-5.0 mEq/L; high levels on avocado, dried fruits, banana,
beef, milk
3. Calcium - 8.8-10.5 mg/dL (T), 4.0-5.9 md/dL (i); high levels in milk and
milk products, dark green leafy vegetables
4. Magnesium - 1.5-2.5 mEq/L; high levels in cereal grains, nuts, dried fruit
5. Chloride - 95-108mEq/L; high levels in foods also rich in sodium
6. Phosphate - 2.5-4.5 mg/dL; high levels in meat, fish, poultry, milk products
and legumes
II. Acid Base Balance - an important part of regulating the homeostasis of body fluids is
regulating their acidity and alkalinity
A. Regulation of Acid-Base Balance
1. Acid - a substance that releases hydrogen ions (H+) in solution
2. Base - has a low hydrogen ion concentration and can accept hydrogen
ions in solution
3. The normal pH of arterial blood is between 7.35 and 7.45, slightly alkaline
4. Buffers - help maintain acid–base balance by neutralizing excess acids or
bases; prevent excessive changes in pH by binding with or releasing
hydrogen ions; i.e bicarbonate
5. Respiratory regulation - lungs help regulate acid–base balance by
eliminating or retaining carbon dioxide (CO2)
6. Renal regulation - kidneys are the ultimate long-term regulator of
acid–base balance, they selectively excrete or conserve bicarbonate and
hydrogen ions
III. Fluid Imbalances
A. Isotonic Imbalances - occur when water and electrolytes are lost or gained in
equal proportions, so that the osmolality of body fluids remains constant 1. Fluid
Volume Deficit - occurs when the body loses both water and
electrolytes from the ECF in similar proportions
2. Fluid Volume Excess - occurs when the body retains both water and
sodium in similar proportions to normal ECF
B. Osmolar Imbalances - involve the loss or gain of only water, so that the
osmolality of the serum is altered
1. Dehydration/Hyperosmolar Imbalance - occurs when water is lost from
the body, leaving the client with excess sodium
2. Overhydration/Hypo-osmolar Imbalance - occurs when water is gained in
excess of electrolytes, resulting in low serum osmolality and low serum
sodium levels
IV. Electrolyte Imbalances
A. Sodium
1. Hyponatremia - serum sodium level of less than 135 mEq/L; increasing
intracranial pressure or coma
2. Hypernatremia - serum sodium of greater than 145 mEq/L; thirst, fatigue,
convulsions, disorientation
B. Potassium
 1. Hypokalemia - Serum potassium < 3.5 mEq/L; muscle weakness, leg
cramps, cardiac dysrythmias, weak reflexes, weak pulses, ECG changes 2.
Hyperkalemia - Serum potassium > 5.0 mEq/L; diarrhea, cardiac arrest,
decreased heart rate, numbness on extremeties, ECG changes
C. Calcium
1. Hypocalcemia - Serum calcium < 8.5 mg/dL (total) or 4.5 mEq/L (ionized);
numbness or tingling around the mouth, muscle tremors or cramps,
Positive Trousseau’s and Chvostek’s signs, ECG changes
2. Hypercalcemia - Serum calcium > 10.5 mg/dL (total) or 5.5 mEq/L
(ionized); lethargy, weakness, weak reflexes, urinary stones, ECG
changes
D. Magnesium
1. Hypomagnesemia - Serum magnesium < 1.5 mEq/L; tremors, increased
reflexes, tachycardia, respiratory difficulties
2. Hypermagnesemia - Serum magnesium > 2.5 mEq/L; flushing, muscle
weakness, weak reflexes, cardiac arrest or coma
E. Chloride
1. Hypochloremia - serum chloride level below 95 mEq/L; muscle twitching,
tremors, or tetany
2. Hyperchloremia - serum chloride level above 108 mEq/L; weakness, and
lethargy, dysrhythmias or coma
F. Phosphate
1. Hypophosphatemia - serum phosphate level of less than 2.5 mg/dL;
paresthesias, muscle weakness and pain, mental changes, and possibly
seizures
2. Hyperphosphatemia - serum phosphate level greater than 4.5 mg/dL;
numbness and tingling around the mouth and in the fingertips, muscle
spasms, and tetany
V. Acid-Base Imbalances
A. Respiratory Acidosis - caused by carbon dioxide retention, causing carbonic acid
levels to increase and pH to fall below 7.35 i.e. asthma
B. Respiratory Alkalosis - caused by increased carbon dioxide exhalation causing
carbonic acid levels to fall, and the pH rises to greater than 7.45 i.e.
hyperventilation
C. Metabolic Acidosis - when bicarbonate levels are low in relation to the amount of
carbonic acid in the body, pH falls i.e. renal failure, starvation
D. Metabolic Alkalosis - the amount of bicarbonate in the body exceeds the normal
causing the pH to rise i.e. ingestion of bicarbonate of soda
VI. Assessment
A. Daily weight
B. Vital signs
C. Fluid intake and output
1. Oral fluids
2. Ice chips
3. Foods that become liquid at room temperature
 4. Tube feedings
5. Parenteral feedings
6. IV medications
7. Catheter or tube irrigants
8. Urinary output
9. Vomitus or liquid feces
10. Tube drainage
11. Wound and fistula drainage
D. Laboratory tests
1. Serum electrolytes
2. Complete blood count
3. Osmolality
4. Urine specific gravity
5. Urine pH
6. Arterial blood gas
VII. Promoting Fluid and Electrolyte Balance
A. Consume six to eight glasses of water daily.
B. Avoid excess amounts of foods or fluids high in salt, sugar, and caffeine. C.
Eat a well-balanced diet. Include adequate amounts of milk, milk products, or
calcium-enriched alternatives to maintain bone calcium levels.
D. Limit alcohol intake because it has a diuretic effect.
E. Increase fluid intake before, during, and after strenuous exercise, particularly
when the environmental temperature is high, and replace lost electrolytes from
excessive perspiration as needed with commercial electrolyte solutions.
F. Maintain normal body weight and body mass index for age and gender.
G. Learn about and monitor side effects of medications that affect fluid and
electrolyte balance (e.g., diuretics) and ways to handle side effects.
H. Recognize possible risk factors for fluid and electrolyte imbalance such as
prolonged or repeated vomiting, frequent watery stools, or inability to consume
fluids because of illness.
I. Seek prompt professional health care for notable signs of fluid imbalance such as
sudden weight gain or loss, decreased urine volume, swollen ankles, shortness
of breath, dizziness, or confusion.
VIII. Facilitating Fluid Intake
A. Explain to the client the reason for the required intake and the specific amount
needed. This provides a rationale for the requirement and promotes compliance. B.
Establish a 24-hour plan for ingesting the fluids.
C. Set short-term outcomes that the client can realistically meet.
D. Identify fluids the client likes and make available a variety of those items,
including fruit juices, noncaffeinated soft drinks, and milk (if allowed).
Remember
that beverages such as coffee, tea, and other caffeinated beverages have a
diuretic effect, so their consumption should be limited.
E. Help the client to select foods that tend to become liquid at room temperature
(e.g., gelatin, ice cream, sherbet, custard), if these are allowed.
 F. For clients who are confined to bed, supply appropriate cups, glasses, and
straws to facilitate adequate fluid intake, and keep fluids within easy reach. G.
Make sure fluids are served at the appropriate temperature (i.e., hot fluids hot
and cold fluids cold) and according to client preference.
H. Encourage clients to participate in maintaining the fluid intake record if possible.
This assists them to evaluate the achievement of desired outcomes.
I. Be alert to any cultural implications of food and fluids. Some cultures may restrict
certain foods and fluids, or temperatures of foods and fluids, and view others as
having healing properties.
IX. Helping Clients Restrict Fluid Intake
A. Explain the reason for the restricted intake and how much and what types of
fluids are permitted orally.
B. Help the client decide the amount of fluid to be taken with each meal, between
meals, before bedtime, and with medications.
C. Identify fluids or fluid-like substances the client likes and make sure that these
are provided, unless contraindicated.
D. Set short-term goals that make the fluid restriction more tolerable.
E. Place allowed fluids in small containers such as a 4-ounce juice glass to allow
the perception of a full container.
F. Periodically offer the client ice chips as an alternative to water, because ice chips
are approximately half of the frozen volume after they melt.
G. Provide frequent mouth care and rinses to reduce the thirst
sensation.
H. Instruct the client to avoid ingesting or chewing salty or sweet foods (hard candy
or gum), because these foods tend to produce thirst. Sugarless gum or candy
may be an alternative for some clients.
I. Encourage the client to participate in maintaining the fluid intake record if
possible.
X. Parenteral Fluid and Electrolyte Replacement
A. Intravenous Solutions
1. Isotonic Solutions - have the same concentration of solutes as blood
plasma; often used to restore blood volume
a) 0.9% NaCl (normal saline)
b) Lactated Ringer’s (a balanced electrolyte solution)
c) 5% dextrose in water (D5W)
2. Hypotonic Solutions - have a lesser concentration of solutes; used to
provide free water and treat cellular dehydration
a) 0.45% NaCl (half normal saline)
b) 0.33% NaCl (one-third normal saline)
3. Hypertonic Solutions - have a greater concentration of solutes than
plasma; draw fluid out of the intracellular and interstitial compartments
into the vascular compartment, expanding vascular volume
a) 5% dextrose in normal saline (D5NS)
b) 5% dextrose in 0.45% NaCl (D5 1/2NS)
c) 5% dextrose in lactated Ringer’s (D5LR)
 4. Volume expanders - used to increase the blood volume following severe
loss of blood ( or loss of plasma
a) Dextran
b) Plasma
c) Albumin
d) Hespan
B. Peripheral venipuncture sites

1. Vein Selection
a) Use distal veins of the arm first; subsequent IV starts should be
proximal to the previous site.
b) Use the client’s nondominant arm whenever possible.
c) Select a vein that is:
(1) Easily palpated and feels soft and full
(2) Naturally splinted by bone
(3) Large enough to allow adequate circulation around the
catheter.
d) Avoid using veins that are:
(1) In areas of flexion (e.g., the antecubital fossa)
(2) Highly visible, because they tend to roll away from the
needle
(3) Damaged by previous use, phlebitis, infiltration, or
sclerosis
(4) Continually distended with blood, or knotted or tortuous
(5) In a surgically compromised or injured extremity (e.g.,
following a mastectomy), because of possible impaired
circulation and discomfort for the client.
C. Intravenous Infusion Equipment
1. Intravenous Catheters
2. Solution Containers
 3. Infusion Administration Set
4. Intravenous Filters
5. Intravenous Poles

D. Starting an Intravenous Infusion

1. Position the client appropriately. Assist the client to a comfortable
position, either sitting or lying. Expose the limb to be used but provide for
client privacy.
2. Open and prepare the infusion set.
a) Remove tubing from the package and straighten it out.
b) Slide the tubing clamp along the tubing until it is just below the drip
chamber to facilitate its access.
c) Close the clamp.
d) Leave the ends of the tubing covered with the plastic caps until the
infusion is started.
3. Spike the solution container.
a) Expose the insertion site of the bag or bottle by removing the
protective cover.
b) Remove the cap from the spike and insert the spike into the
insertion site of the bag or bottle.
4. Hang the solution container on the pole.
a) Adjust the pole so that the container is suspended about 1 m (3 ft)
above the client’s head.
5. Partially fill the drip chamber with solution.
 a) Squeeze the chamber gently until it is half full of solution.
6. Prime the tubing.
a) Remove the protective cap and hold the tubing over a container.
Maintain the sterility of the end of the tubing and the cap.
b) Release the clamp and let the fluid run through the tubing until all
bubbles are removed. Tap the tubing if necessary with your fingers
to help the bubbles move.
c) Reclamp the tubing and replace the tubing cap, maintaining sterile
technique.
7. Select the venipuncture site.
8. Dilate the vein.
a) Place the extremity in a dependent position (lower than the client’s
heart).
b) Apply a tourniquet firmly 15 to 20 cm (6 to 8 in.) above the
venipuncture site.
c) If the vein is not sufficiently dilated:
(1) Massage or stroke the vein distal to the site and in the
direction of venous flow toward the heart.
(2) Encourage the client to clench and unclench the fist.
(3) Lightly tap the vein with your fingertips.
9. Apply clean gloves and clean the venipuncture site. Clean the skin at the
site of entry with a topical antiseptic swab
10. Insert the catheter and initiate the infusion.
a) Remove the catheter assembly from its sterile packaging.
b) Remove the cover of the needle (stylet)
c) Use the nondominant hand to pull the skin taut below the entry
site.
d) Holding the over-the-needle catheter at a 15- to 30-degree angle
with needle (stylet) bevel up, insert the catheter through the skin
and into the vein. A sudden lack of resistance is felt as the needle
(stylet) enters the vein. Use a slow steady insertion technique and
avoid jabbing or stabbing motions.
e) Once blood appears in the lumen or clear “flashback” chamber of
the needle, lower the angle of the catheter until it is almost parallel
with the skin, and advance the needle (stylet) and catheter
approximately 0.5 to 1 cm (about 1/4 in.) farther.
f) If there is no blood return, try redirecting the catheter assembly
again toward the vein. If the stylet has been withdrawn from
the
catheter even a small distance, or the catheter tip has been pulled
out of the skin, the catheter must be discarded and a new one
used.
g) If blood begins to flow out of the vein into the tissues as the
catheter is inserted, creating a hematoma, the insertion has not
been successful. This is sometimes referred to as a blown vein.
 Immediately release the tourniquet and remove the catheter,
applying pressure over the insertion site with dry gauze.
Attempt the venipuncture in another site, in the opposite arm if
possible.
11. Release the tourniquet.
12. Put pressure on the vein proximal to the catheter to eliminate or reduce
blood oozing out of the catheter. Stabilize the hub with thumb and index
finger of the nondominant hand.
13. Remove the protective cap from the distal end of the tubing and hold it
ready to attach to the catheter, maintaining the sterility of the end. 14.
Stabilize the catheter hub and apply pressure distal to the catheter with
your finger.
15. Carefully remove the stylet, engage the needle safety device if it does
not engage automatically, and attach the end of the infusion tubing to the
catheter hub. Place the stylet directly into a sharps container. If this is not
within reach, place the stylet into its original package and dispose in a
sharps container as soon as possible.
16. Secure the catheter according to the manufacturer’s instructions and
agency policy.
17. Ensure appropriate infusion flow.
18. Label the IV tubing.
E. Regulating Intravenous Infusions
1. Drop Factor - number of drops delivered per milliliter of solution varies
with different brands and types of infusion sets
a) Macrodrops/Macroset. 20 drops/mL
b) Microdrops/Microset - 60 drops/mL
2. Milliliters per hour

3. Drops per minute

F. Monitoring Intravenous Infusions

1. Ensure that the correct solution is being infused.
2. Observe the rate of flow every hour.
a) Compare the rate of flow regularly, for example, every hour,
against the infusion schedule
b) Observe the position of the solution container. If it is less than 1 m
(3 ft) above the IV site, readjust it to the correct height of the pole. 3. Inspect
the patency of the IV tubing and catheter
a) Observe the drip chamber.
b) Inspect the tubing for kinks or obstructions to flow
 c) Observe the position of the tubing.
d) Determine catheter position.
4. Inspect the insertion site for fluid infiltration.
5. Inspect the insertion site for phlebitis (inflammation of a vein).
6. Inspect the IV site for bleeding.
G. Changing an Intravenous Container and Tubing
1. Set up the IV equipment with the new container and label.
2. Assess the IV site.
a) Inspect the IV site for the presence of infiltration or inflammation.
b) Discontinue and relocate the IV site if indicated.
3. Clamp the tubing.
a) With the fourth or fifth finger of the non-dominant hand, apply
pressure to the vein above the end of the catheter
4. Holding the hub of the catheter with the thumb and index finger of the
nondominant hand, remove the tubing or cap with the dominant hand,
using a twisting and pulling motion.
5. Remove the used IV tubing.
6. Connect the new tubing or cap and reestablish the infusion.
a) Continue to hold the catheter and grasp the new tubing with the
dominant hand.
b) Remove the protective tubing cap and, maintaining sterility, insert
the tubing end securely into the needle hub. Twist it to secure it. c)
Open the clamp to start the solution flowing.
7. Secure IV tubing with additional tape as required.
8. Regulate the rate of flow of the solution according to the order on the
chart.
H. Discontinuing an Intravenous Infusion
1. Clamp the infusion tubing.
2. Remove the dressing, stabilization device, and tape at the venipuncture
site while holding the needle firmly and applying countertraction to the
skin.
3. Apply the sterile gauze above the venipuncture site. Only touch the upper
portion of the gauze pad and maintain sterility of the lower portion that is
in contact with the venipuncture site.
4. Withdraw the catheter from the vein. Withdraw the catheter by pulling it
out along the line of the vein.
5. Immediately apply firm pressure to the site, using sterile gauze, for 2 to 3
minutes.
6. Hold the client’s arm above heart level if any bleeding persists. 7.
Cover the venipuncture site. Apply new sterile dressing to the site with
tape.