A Lecturette on

INTRAVENOUS FLUID

In Partial Fulfillment of the

Requirements in NCM 218 - RLE

PRIMARY CARE NURSING ROTATION

Submitted to:
CHARMAINE OROCIO, RN
Clinical Instructor

Submitted by:
SUHARTO PENDALIDAY, St.N
JEROME REX SANTOS, St.N
CLARISSA S. TORRES, St.N
BSN 4F - GROUP 5

October 15, 2021

DEFINITION

• IV stands for “intravenous” or “inside the vein”, which means that the patient
receives substances directly to their veins through a tube called a cannula. This
therapy is a treatment that infuses intravenous solutions, medications, blood, or
blood products directly into a vein (Sonas Home Health Care, 2018).

• Intravenous therapy is an effective and fast-acting way to administer fluid or

medication treatment in an emergency situation, and for patients who are unable
to take medications orally.

• Intravenous therapy is the aseptic instillation of fluid, electrolytes, nutrients, or

medications through a needle into a vein.

PURPOSES

• To administer fluids and chemical substances when circumstances prevent the

client from consuming a normal diet and oral liquids

• To replace fluids and chemical substances when the client has experienced their
loss through diarrhea, vomiting, bleeding, etc…

• To provide access to the circulatory system if it becomes necessary to administer

emergency medications

• To maintain an access to the circulatory system for the intermittent administration

of scheduled medications

INTRAVENOUS FLUID CLASSIFICATION

Intravenous solutions can be classified into many types. First, according to their
purpose:

1. Nutrient solutions. May contain dextrose, glucose, and levulose to make up the
carbohydrate component – and water. Water is supplied for fluid requirements and
carbohydrate for calories and energy. Nutrient solutions are useful in preventing
dehydration and ketosis. Examples of nutrient solutions include D5W, D5NSS.

2. Electrolyte solutions. Contains varying amounts of cations and anions that are
used to replace fluid and electrolytes for clients with continuing losses. Examples
of electrolyte solutions include 0.9 NaCl, Ringer’s Solution, and LRS.

3. Alkalinizing solutions. Are administered to treat metabolic acidosis. Examples:

LRS.

4. Acidifying solutions. Are used to counteract metabolic alkalosis. D51/2NS, 0.9

NaCl.
 5. Plasma Volume expanders. Are solutions used to increase the blood volume
after a severe blood loss, or loss of plasma. Examples of volume expanders are
dextran, human albumin, and plasma.

Second, intravenous solutions can be classified according to the type of plasma

volume expanders:

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 disadvantages are cost and the
risk of volume overload, including pulmonary edema. Colloids are more effective for the
resuscitation of plasma volume compared with crystalloids. The duration of action is also
longer than that of crystalloids. They are very similar to blood containing albumin and
plasma.

Examples:

• Human Albumin

Human albumin is a solution derived from plasma. It has two strengths: 5%

albumin and 25% albumin. 5% Albumin is a solution derived from plasma and is a
commonly utilized colloid solution. It is used to increase the circulating volume and
restore protein levels in conditions such as burns, pancreatitis, and plasma loss
through trauma. 25% Albumin is used together with sodium and water restriction to
reduce excessive edema. They are considered blood transfusion products and uses
the same protocols and nursing precautions when administering albumin.

• Dextrans

Dextrans are polysaccharides that act as colloids. They are available in two
types: low-molecular-weight dextrans (LMWD) and high-molecular-weight dextrans
(HMWD). They are available in either saline or glucose solutions. Dextran interferes
with blood crossmatching, so draw the patient’s blood before administering dextran, if
crossmatching is anticipated.

2. Crystalloids

Crystalloids are acqueous aolutions that contain mineral salts and other small
water-soluble molecules. They are frequently used in the clinical serting as the first choice
to increase intravascular volume. They also work much like colloids but do not stay in the
intravascular circulation as well as colloids do, so more of them need to be used. They
are 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 lactated ringer’s solution. Moreover, crystalloids can be classified into three
(3): isotonic, hypotonic, and hypertonic.

Third, intravenous solutions can be classified according to their tonicity:

Intravenous fluids are often categorized as isotonic, hypotonic, or hypertonic,

according to whether their total osmolality is the same as, less than , or greater than that
of blood.

1. Isotonic Solutions

Fluids that are classified as isotonic have a total osmolality close to that of the ECF
and do not cause red blood cells to shrink or swell. The composition of these fluids may
or may not approximate that of the ECF. Isotonic fluids expand the ECF volume. One liter
of isotonic fluid expands the ECF by 1L. However, it expands the plasma by only 0.25 L
because it is a crystalloid fluid and diffuses quickly into the ECF compartment. For the
same reason, 3 L of isotonic fluid is needed to replace 1 L of blood loss. Because these
fluids expand the intravascular space, patients with hypertension and heart failure should
be carefully monitored for signs of fluid overload.

Examples:

• Normal Saline (0.9% Sodium Chloride)

When administered to a patient requiring water, it neither enters cells nor pulls
water from cells; it therefore expands the extracellular fluid volume. For this reason,
normal saline solution is often used to correct an extracellular volume deficit. Although
referred to as “normal”, it contains only sodium and chloride and does not actually
simulate the ECF. It is used with administration of blood transfusions and to replace
large sodium losses, as in burn injuries. It is not used for heart failure, pulmonary
edema, renal impairment, or sodium retention. Normal saline does not supply calories.

• Lactated Ringers Solution

Lactated Ringer’s solution contains 130 mEq/L of sodium, 4 mEq/L of

potassium, 3 mEq/L of calcium, and 109 mEq/L of chloride. It is used to correct
dehydration and sodium depletion and replace GI losses. Lactated ringer’s solution
contains bicarbonate precursors to prevent acidosis. It is the most physiologically
adaptable fluid because its electrolyte content is most closely related to the
composition of the body’s blood serum and plasma.

Nursing Implications

• Monitor for fluid overload; discontinue fluids and notify the healthcare
provider.
• Do not administer lactated ringer’s solution to patients with severe
liver disease as the liver may be unable to convert the lactate to
 bicarbonate and the patient may become acidotic. Do not administer
if the patient has a blood pH of >7.50.
• If administering lactated ringer’s solution, monitor potassium levels
and cardiac rhythm; if abnormalities are present, notify the health
care provider.

2. Hypotonic Solution

Hypotonic solutions have lesser concentration of solutes than plasma. They cause
fluid shifts from the ECF into the ICF to achieve homeostasis, therefore causing cells to
swell and may even rupture. Hence, it is used in patients with cellular dehydration. They
are also used as fluid maintenance therapy. Excessive infusions of hypotonic solutions
can lead to intravascular fluid depletion, decreased blood pressure, cellular edema, and
cell damage. These solutions exert less osmotic pressure than the ECF.

Examples:

• 0.45% Sodium Chloride (0.45% NaCl)

Sodium Chloride 0.45 % (1/2 NS), also known as half-strength normal saline,
is a hypotonic IV solution used for replacing water in patients who have hypovolemia
with hypernatremia. Excess use may lead to hyponatremia due to dilution of sodium,
especially in patients who are prone to water retention. It has an osmolality of 154
mEq/L sodium and chloride. Hypotonic sodium solutions are used to treat
hypernatremia and other hyperosmolar conditions.

• 0.33 Sodium Chloride (0.33% NaCl)

0.33 Sodium Chloride solution is used to allow kidneys to retain the needed
amounts of water and is typically administered with dextrose to increase tonicity.
It should be use in caution for patients with heart failure and renal insufficiency.

• Dextrose 5% in Water (D5W)

A solution of D5W has a serum osmolality of 252 mOsm/L. Once administered,

the glucose is rapidly metabolised, and this initially isotonic solution then disperses as
a hypotonic fluid, one-third extracellular and two-thirds intracellular. It is essential to
consider this action of D5W, especially if the patient is at risk for increased intracranial
pressure. During fluid resuscitation, this solution should not be used because it can
cause hyperglycemia. Therefore, D5W is used mainly to supply water and to correct
an increased serum osmolality. About 1L of D5W provides fewer than 200 kcal and is
a minor source of calories for the body’s daily requirements.

Nursing Implications

1. Monitor for inflammation and infiltration at IV insertion sites as hypotonic

solutions may cause cells to swell and burst, including those at the insertion site;
this narrows the lumen of the vein.
 2. Monitor blood sodium levels.

3. Do not administer in contraindicated conditions. Hypotonic solutions may

exacerbate existing hypovolemia and hypotension causing cardiovascular
collapse.

4. Do not administer to patients at risk for increased intracranial pressure (e.g

head trauma, stroke, neurosurgery) as this may cause cerebral edema.

5. Do not administer to patients at risk for third-space shifts (burns, trauma,

liver disease, malnutrition).

3. Hypertonic Solution

Hypertonic solutions have greater concentration of solutes than plasma. They are
used to expand the plasma volume, as in the hypovolemic patient. They are also used
to replace electrolytes. These solutions draw water from the ICF to the ECF and cause
cells to shrink. If administered rapidly or in large quantities, they may cause an
extracellular volume excess and precipitate circulatory overload and dehydration. As a
result, these solutions must be administered cautiously and usually only when the serum
osmolality has decreased to dangerously low levels. Hypertonic solutions exert an
osmotic pressure greater than that of the ECF.

Examples:

• Dextrose 10% in Water (D10W)

Dextrose 10% in Water is an hypertonic solution used in the treatment of

ketosis of starvation and provides calories (380 kcal/L), free water, and no
electrolytes. It should be administered using central line if possible and should not be
infused using the same line as blood products as it can cause RBC hemolysis.

• 5% dextrose in lactated Ringer’s Solution

5% Dextrose in Lactated Ringer’s solution provides electrolytes and calories,

and is a source of water for hydration. It is capable of inducing diuresis depending on
the clinical condition of the patient. This solution also contains lactate which produces
metabolic alkalinizing effect.

Nursing Implications

1. Monitor for inflammation and infiltration at IV insertion site as hypertonic

solutions cause cells to shrink, exposing the basement membrane of the vein.

2. Monitor blood sodium levels.

3. Monitor for signs of hypervolemia. Since hypertonic solutions move fluid from the
ICF to the ECF, they increase the extracellular fluid volume and increases the risk
 for hypervolemia. Look for signs of swelling in arms, legs, face, shortness of
breath, high blood pressure, and discomfort in the body (e.g., headache, cramping,
etc.)

4. Do not administer to patients with diabetic ketoacidosis or impaired cardiac or

kidney function.

5. Do not administer peripherally. Hypertonic solutions can cause irritation and

damge to blood vessels and should be administered through a central vascular
access device inserted into a central vein.

6. Monitor blood glucose closely. Rapid infusion of hypertonic dextrose solutions can
cause hyperglycemia. Use with caution for patients with diabetes mellitus.

COMPLICATIONS OF INTRAVENOUS THERAPY

Local Complications Signs and Management

Symptoms

Infiltration • Swelling, Prevention

- occurs when I.V. fluid or
medications leak into the
surrounding tissue. Infiltration
can be caused by improper
placement or dislodgement of
the catheter. Patient
movement can cause the
catheter to slip out or through
the blood vessel lumen.
discomfort, • Select an appropriate I.V.
burning, and/or site, avoiding areas of
tightness flexion.
• Cool skin and • Use proper venipuncture
blanching technique.
• Decreased or • Follow your facility policy
stopped-flow rate for securing the I.V.
catheter.
• Observe the I.V. site
frequently.
• Advise the patient to
report any swelling or
tenderness at the I.V.
site.
Management
• Stop the infusion and
remove the device.
• Elevate the limb to
increase patient comfort;
a warm compress may be
applied.
• Check the patient's pulse
and capillary refill time.
• Perform venipuncture in a
different location and

Extravasation
- Extravasation is the leaking
of vesicant drugs into the
surrounding tissue.
Extravasation can cause
severe local tissue damage,
possibly leading to delayed
healing, infection, tissue
necrosis, disfigurement, loss
of function, and even
amputation.
restart the infusion, as
ordered.
• Check the site frequently.
• Document your findings
and interventions
performed.
Prevention
• Avoid veins that are small
• Blanching, and/or fragile, veins in
burning, or areas of flexion, veins in
discomfort at the extremities with
I.V. site preexisting edema, or
• Cool skin around veins in areas with known
the I.V. site neurologic impairment.
• Swelling at or • Be aware of vesicant
above the I.V. site medications, such as
• Blistering and/or certain antineoplastic
skin sloughing drugs (doxorubicin,
vinblastine, and
vincristine), and
hydroxyzine,
promethazine, digoxin,
and dopamine.
• Follow your facility policy
regarding vesicant
administration via a
peripheral I.V.; some
institutions require that
vesicants are
administered via a central
venous access device
only.
• Give vesicants last when
multiple drugs are
ordered.
• Strictly adhere to proper
administration
techniques.
Management
• Stop the I.V. flow and
remove the I.V. line,
unless the catheter
should remain in place to
administer the antidote.

Phlebitis
- Phlebitis is inflammation of a
vein. It is usually associated
with acidic or alkaline solutions
or solutions that have a high
osmolarity. Phlebitis can also
occur as a result of vein
trauma during insertion, use of
an inappropriate I.V. catheter
size for the vein, or prolonged
use of the same I.V. site.
• Estimate the amount of
extravasated solution and
notify the prescriber.
• Administer the
appropriate antidote
according to your facility's
protocol.
• Elevate the extremity.
• Perform frequent
assessments of
sensation, motor function,
and circulation of the
affected extremity.
• Record the extravasation
site, your patient's
symptoms, the estimated
amount of extravasated
solution, and the
treatment.
• Follow the manufacturer's
recommendations to
apply either cold or warm
compresses to the
affected area.
• Redness or Prevention
tenderness at the • Use proper venipuncture
site of the tip of technique.
the catheter or • Use a trusted drug
along the path of reference or consult with
the vein the pharmacist for
• Puffy area over instructions on drug
the vein dilution, when necessary.
• Warmth around • Monitor administration
the insertion site rates and inspect the I.V.
site frequently.
• Change the infusion site
according to your facility's
policy.
Management
• Stop the infusion at the
first sign of redness or
pain.
• Apply warm, moist
compresses to the area.

Hypersensitivity
- An immediate, severe
hypersensitivity reaction can
be life-threatening, so prompt
recognition and treatment are
imperative.
Infection
- Local or systemic infection is
another potential complication
of I.V. therapy.
• Document your patient's
condition and
interventions.
• If indicated, insert a new
catheter at a different
site, preferably on the
opposite arm, using a
larger vein or a smaller
device and restart the
infusion.
• Sudden fever Prevention
• Joint swelling • Ask the patient about
• Rash and urticaria personal and family
• Bronchospasm history of allergies.
• Wheezing • For infants younger than
3 months, ask the mother
about her allergy history
because maternal
antibodies may still be
present.
• Stay with the patient for
five to 10 minutes to
detect early signs and
symptoms of
hypersensitivity.
• If the patient is receiving
the drug for the first or
second time, check him
every five to 10 minutes
or according to your
facility's policy.
Management
• Discontinue the infusion
and notify the prescriber
immediately.
• Administer medications
as ordered.
• Monitor the patient's vital
signs and provide
emotional support.
• Redness and Prevention
discharge at the • Perform hand hygiene,
I.V. site don gloves, and use

Hematoma
- Hematomas occur when
blood leaks into the
extravascular space.
Thrombosis
- Thrombosis occurs when the
platelets adhere to the tunica
intima of the vein due to
vessel injury during
venipuncture.
• Elevated aseptic technique during
temperature I.V. insertion.
• Increase WBC • Clean the site with
count approved skin antiseptic
before inserting I.V.
catheter.
• Ensure careful hand
hygiene before any
contact with the infusion
system or the patient.
• Clean injection ports
before each use.
• Follow your institution’s
policy for dressing
changes and changing of
the solution and
administration set.
Management
• Stop the infusion and
notify the prescriber.
• Remove the device, and
culture the site and
catheter as ordered.
• Administer medications
as prescribed.
• Monitor the patient's vital
signs.
• The patient will Management
have tenderness • The IV catheter must be
at the site; removed and restarted
• a bruise may be elsewhere.
evident at the site; • Additionally, you should
• the infusion will apply pressure until the
not flow bleeding stops and warm
soaks to aid in the
absorption of the blood
• Elevate extremity
• The vein will Management
appear painful, • If thrombosis occurs, you
red and swollen will need to remove the
• The IV infusate IV catheter and restart
will not run the IV in the opposite arm
quickly. if at all possible.

Venous Spasm
- Venous spasm occurs due to
severe vein irritation,
administration of cold fluids or
blood, and a very rapid flow
rate.
Systemic Complications
Pulmonary edema
- Also known as fluid or
circulatory overload. A
condition caused by excess
fluid accumulation in the
lungs due to excess fluid in
the circulatory system and
inability of the body to
adapt.
Air embolism
- The presence of air in the
vascular system. 10 ml of
air has been proven to have
serious effects and is
sometimes fatal. Tiny air
bubbles are tolerated by
most patients.
• Apply cold compress to
the site
• The patient will Management
experience pain at • warm soaks over the
the IV site; vein
• the flow rate will • reduction in the flow rate
become sluggish of the infusate
even if the roller • Restart infusion in new
clamp is wide site if spasm continues
open
• the skin will be
blanched over the
vein
Signs and Symptoms Management
• ↓SpO2 Prevention
• ↑respiratory rate • Use IV controller /
• Dyspnea pump to prevent
• coughing up pink frothy accidental bolus.
sputum Management
• auscultation of dependent • Must be immediate.
fine crackles ↑HOB, administer
oxygen, notify
prescriber.
• Anticipate diuretics
and slowed IV rates.
• Lightheadedness Prevention
• Dyspnea • Clamp extensions
• Cyanosis when not in use.
• Tachypnea • IV equipment with
• Expiratory wheezes Luer locks
• Cough • fill drip chambers 1/2
• Chest pain to 1/3 full
• Hypotension • use IV controller /
• Changes in mental status pump
• coma • remove all air from
tubing when priming
• prime IV tubing prior
to attaching to the
patient.
Management
 • Call for help!
• Occlude source of
air entry
• Place patient in
Trendelenburg
position on left side
(if not
contraindicated),
• administer oxygen
• Monitor vital signs
• notify physician

Septicemia • Fluctuating temperature Management

- Also known as • Profuse sweating • Restart new IV
sepsis or blood • Nausea/ Vomiting system
poisoning, is a life • Diarrhea • Obtain cultures
threatening • Abdominal pain • Notify physician
condition whereby • Tachycardia • Initiate antimicrobial
a large number of • Hypotension therapy as ordered
toxic bacteria are • Altered mental status • Monitor patient
present in the closely
blood stream. This
condition occurs
when a person has
an infected site
such as an
injecting point.

REGULATING INTRAVENOUS FLUIDS: STANDARD FORMULA

SAMPLE EXERCISES

1. At 8:20 am, a patient is ordered to receive 1,000 cc of PNSS to be administered

at 120 cc/hour (macroset = 20gtts/cc). Solve for the rate, duration and due time.
Solution:

Duration

1000 cc / 200 cc = 8.33 hours

0.33 X 60 = 19.8 or 20

Duration = 8 hours and 20 minutes

Due Time: 4:40 pm

Rate

1000 cc x 20 gtts/cc
8.33 hrs x 60 min/hr

1000 gtts.
24.99 min.

Rate = 40.01 or 40 gtts/min.

2. The physician orders PNSS 1L to run in 7 hrs. The set is calibrated for a drop factor
of 20 gtts/cc. a) What is the flow rate in cc/hr? b) What is the flow rate in drops per
minute (gtts/min)? c) What is the due time? d) What will be the IV level at exactly
12 pm if the IV administration started at 7:00 am?

Solution:

a. Flow rate in gtts/min.

1000 cc x 20 gtts/cc
7 hrs. x 60 min/hr

20000 gtts
420 mins.

Rate: 47.6 or 48 gtts/min.

b. Flow rate in cc/hr

Volume
Time

1000 cc
7 hrs

= 142.8 or 143 cc/hr

 c. Due Time: 7 hrs. = 2:00 pm

d. IV level at 12:00 pm

1000 cc
7 hrs

= 143 cc/hr

143 cc/hr x 5 hrs = 715 cc

1000 – 715 = 285 cc will be the IV level after 5 hours of continuous therapy

3. IVF to follow D5NSS 1L to run in 7hrs

a. Compute for gtts/min (20gtts/cc)

b. Compute cc/hr
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1)/complications-of-peripheral-i-v-therapy

Complications of Peripheral Intravenous Therapy (2019). Complications of Peripheral

Intravenous Therapy. Fluid & Medication Management. Retrieved from
https://edu.cdhb.health.nz/Hospitals-Services/Health-Professionals/CDHB-
Policies/Fluid-Medication-Manual/Documents/Complications-Of-IV-Therapy.pdf

Hinkle, J. & Cheever, K. (2018). Parenteral Fluid Therapy. Brunner & Suddarth’s
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