HOMEOSTASIS Electrolyte Concentration in Body Fluids

Intracellular Fluid Extracellular Fluid

• Homeostasis is the dynamic process in which the
Major Cations Major Cations
body maintains balance by constantly adjusting - Potassium - Sodium
to internal and external stimuli. - Magnesium - Potassium
• Fluid and electrolyte balance are necessary to - Sodium - Calcium
- Magnesium
maintain homeostasis.
• An equal balance of intake and output helps the
human body maintain proper equilibrium within Electrolyte Concentration in Body Fluids
all body systems.
Intracellular Fluid Extracellular Fluid
• Intake and output of water is regulated by the
Major Anions Major Anions
kidneys, the pulmonary system, and hormonal
- Phosphorus - Chloride
and neural functions. - Phosphorus

FLUID COMPARTMENTS
FLUID AND ELECTROLYTE MOVEMENT

The Body Cells

• Nutrients and oxygen should enter body cells
while waste products should exit the body.

The Cell Membrane

• the cell membrane separates the intracellular
environment from the extracellular environment.

Permeability
• the ability of a membrane to allow molecules to
pass through is known as permeability.
o Freely Permeable membranes – these
membranes allow almost any food or
waste substance to pass through.
This illustration shows the primary fluid compartments in o Selectively Permeable – each cell’s
the body: intracellular and extracellular. The extracellular membrane allows only certain specific
compartment is further divided into interstitial and substances to pass through.
intravascular fluids. Capillary walls and cell membranes
PASSIVE TRANSPORT
separate intracellular fluids from extracellular fluids.
• Diffusion. Movement of molecules from an area
ANIONS AND CATIONS of high concentration to one of low concentration.
• Osmosis. The movement of water across a
• electrolytes are substances that separate or
semipermeable membrane from areas of low
dissociate into ions (charged particles) in
solute concentration to those of high solute
solution, and they are abundant in both ICF and
concentration.
ECF.
• Hydrostatic Pressure. The force within a fluid
compartment.
• Cation – positive charge
• Filtration. The transport of water and dissolved
➢ Potassium (K+)
materials concentration already exists in the cell.
➢ Sodium (Na+)
➢ Calcium (Ca2+) ACTIVE TRANSPORT
➢ Magnesium (Mg2+)
• Solutes move from an area of lower
• Anion – negative charge concentration to an area of higher concentration.
➢ Chloride (Cl-) Like fish swimming upstream, active transport
➢ Bicarbonate (HCO3-) requires energy to make it happen.
➢ Phosphate (PO4-) • Active transport mechanisms require specific
➢ Sulfate (SO4-) enzymes and energy expenditure in the form of
adenosine triphosphate (ATP).
DIFFUSION
In diffusion, solutes move from areas of higher
concentration to areas of lower concentration until their
concentration is equal in both areas.
IV Solutions can also be classified based on their
purpose
OSMOSIS
In osmosis, fluid moves passively from areas with more
fluid (and fewer solutes) to areas with less fluid (and more
solutes).
▪ osmosis – fluid moves
▪ diffusion – solutes move
OSMOLALITY
• Describes the concentration of fluids.
• Refers to the number of particles dissolved in the
serum, primarily sodium, urea (blood urea
nitrogen [BUN]), and glucose.
• It is also a measure of the concentration of
solutes per kilogram in urine.
• Normal serum osmolality ranges from 275 to 295
1. Crystalloid solutions
mOsm/kg
TYPES OF FLUID CONCENTRATION ARE BASED ON
THE OSMOLALITY OF BODY FLUIDS
• Iso-osmolar fluid has the same weight
proportion of particles (e.g., sodium, glucose)
and water.
• Hypo-osmolar fluid contains fewer particles than
water.
• Hyper-osmolar fluid contains more particles
than water.
INTRAVENOUS (IV) THERAPY
• It is an efficient and effective way of supplying
fluids directly into the intravascular compartment,
in replacing electrolyte losses, and in
administering medications in blood products.
• Intravenous fluids (IV Fluids), also known as
intravenous solutions, are supplemental fluids
used in intravenous therapy to restore or
maintain normal fluid volume and electrolyte
balance when the oral route is not possible.
• Nutrient solutions. May contain dextrose,
glucose, and levulose to make up the
carbohydrate component – and water. Water is
supplied for fluid requirements and
carbohydrates for calories and energy. Nutrient
solutions are useful in preventing dehydration
and ketosis. Examples of nutrient solutions
include D5W, D5NSS.
• 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.
• Alkalinizing solutions. Are administered to treat
metabolic acidosis. Examples: LRS
• Acidifying solutions. Are used to counteract
metabolic alkalosis. D51/2NS, 0.9 NaCl.
• 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.
TYPES OF SOLUTIONS
❖ Crystalloid Solutions
❖ Colloid
❖ Blood and Blood Products
- Contain fluids and electrolytes and freely cross
capillary walls.
- They do not contain any proteins, which are
necessary to maintain the colloidal oncotic
pressure that prevents water from leaving the
intravascular space.
- Crystalloids are used as short-term maintenance
fluids and to treat dehydration and electrolyte
imbalances.
- Crystalloids cause early plasma expansion but
have a shorter duration of action than colloid
solutions.
Three (3) major classifications of crystalloid:
o Isotonic (normal cell)
- Isotonic fluids, such as normal
saline solution, have a
concentration of dissolved
particles, or tonicity, equal to that
 of intracellular fluid (ICF).
Osmotic pressure is therefore
the same inside and outside the
cells, so they neither shrink nor
swell with fluid movement.
o Hypertonic (cell shrinks)
- Hypertonic fluid has tonicity
greater than that to ICF, so
osmotic pressure is unequal
inside and outside the cells.
Dehydration or a rapidly infused
hypertonic fluid, such as 3%
saline or 50% dextrose, draws
water out of the cells into the
more highly concentrated
extracellular fluid (ECF)
o Hypotonic (cell swells)
- Hypotonic fluids, such as half-
normal saline solution, have a
tonicity less than that of ICF, so
osmotic pressure draws water
into cells from the ECF. Severe
electrolyte losses or
inappropriate use of I.V fluids
can make body fluids hypotonic.
Normal Saline Solution (NSS) (0.9% NaCl)
Uses
Osmolality • Isotonic solution of choice for
• 308 mOsm/L expanding ECF volume.
• Infused to correct ECF deficit.
Contains: • Used alongside
• Water administration of blood
• Sodium (154meq/L) products.
• Chloride (154meq/L) • Used to replace large sodium
loss such as burn injuries and
trauma.
Caution
• Should not use for patients
with heart failure, pulmonary
edema and renal impairment.
Dextrose 5% in Water (D5W)
Uses
Osmolality • Initially isotonic and provides
• 252 mOsm/L free water when dextrose is
metabolized.
Contains: • Expands ECF and ICF,
• Water helpful in rehydrating and
• Glucose excretory process.
• Used to treat hypernatremia
Caution
• Should not be used for fluid
resuscitation because it may
cause hyperglycemia. Should
be avoided with patients at
risk for increased ICP.
Ringer’s Solution
Uses
Osmolality • Used to correct dehydration,
• 273 mOsm/L sodium depletion and replace
GI tract fluid loses.
Contains: • Also used in fluid losses
• Water caused by burns, fistula
• Sodium (130meq/L) drainage and trauma.
• Potassium (4meq/L) • Often administered to patients
• Calcium (3meq/L) with metabolic acidosis
• Chloride (109meq/L) because it is an alkalizing
solution.
Caution
• Used in caution for patients
with heart failure and renal
failure.
Nursing Considerations for Isotonic IV Solutions
• Document baseline data. Before infusion,
assess the patient’s vital signs, edema status,
lung sounds, and heart sounds. Continue
monitoring during and after the infusion.
• Observe for signs of fluid overload. Look for
signs of hypervolemia such as hypertension,
bounding pulse, pulmonary crackles, dyspnea,
shortness of breath, peripheral edema, jugular
venous distention, and extra heart sounds.
• Monitor manifestations of continued
hypovolemia. Look for signs that indicate
continued hypovolemia such as, decreased urine
output, poor skin turgor, tachycardia, weak pulse,
and hypotension.
• Prevent hypervolemia. Patients being treated
for hypovolemia can quickly develop fluid
overload following rapid or over infusion of
isotonic IV fluids.
• Elevate the head of the bed at 35 to 45
degrees. Unless contraindicated, position the
client in semi-Fowler’s position.
• Elevate the patient’s legs. If edema is present,
elevate the legs of the patient to promote venous
return.
• Educate patients and families. Teach patients
and families to recognize signs and symptoms of
fluid volume overload. Instruct patients to notify
their nurse if they have trouble breathing or notice
any swelling.
• Close monitoring for patients with heart
failure. Because isotonic fluids expand the
intravascular space, patients with hypertension
and heart failure should be carefully monitored
for signs of fluid overload.
 0.33% Sodium Chloride Solution (0.33% NaCl) Hypertonic Sodium Chloride Solution
Uses Uses
Osmolality • Used to allow kidneys to 3% NaCl • Used in acute treatment of
• 365 mOsm/L retain needed amounts of • Sodium (513meq/L) severe hyponatremia and
(hypotonic one dextrose water. Free water helps • Chloride (513meq/L) should be only used in
is metabolized) kidneys eliminate solutes. • 1030 mOsm/L critical situations to treat
• Typically administered with hyponatremia.
Contains: dextrose to increase 5% NaCl • Used in patients with
• Water tonicity. • Sodium (855meq/L) cerebral edema.
• Sodium (56meq/L) • Chloride (855meq/L) • Some patients may need
• Chloride (56meq/L) Caution • 1710 mOsm/L diuretics to assist in fluid
• Glucose (50g/L) • Used in caution for patients excretion.
• 170 kcal/L with heart failure and renal
insufficiency. Caution
• Should be infused at a very
low rate to avoid risk of
pulmonary edema.
Nursing Considerations for Hypotonic IV Solutions
• If administered in large
• Document baseline data. Before infusion, quantities and rapidly, they
may cause ECF excess and
assess the patient’s vital signs, edema status, circulatory overload.
lung sounds, and heart sounds. Continue
monitoring during and after the infusion.
D10% Water (D10W)
• Do not administer in contraindicated Uses
conditions. Hypotonic solutions may exacerbate Osmolality • Used in treatment of ketosis
existing hypovolemia and hypotension causing • 505 mOsm/L of starvation and provides
calories and free water.
cardiovascular collapse. Avoid use in patients Contains
with liver disease, trauma, or burns. • Water Caution
• Glucose • Should be administered in
• 380 kcal/L central line as possible.
• Risk for increased intracranial pressure • Do not infuse using the
(IICP). Should not be given to patients with risk same line as blood products
as it can cause RBC
for IICP as the fluid shift may cause cerebral
hemolysis.
edema (remember: hypotonic solutions make
cells swell).
D50% Water (D50W)
• Monitor for manifestations of fluid volume Uses
deficit. Signs and symptoms include confusion in Osmolality • Used to treat severe
older adults. Instruct patients to inform the nurse • 2523 mOsm/L hypoglycemia.
• Administer rapidly via IV
if they feel dizzy. Contains bolus.
• Water
• Warning on excessive infusion. Excessive • Glucose 500g/L
infusion of hypotonic IV fluids can lead to
intravascular fluid depletion, decreased blood
Nursing Considerations for Hypertonic IV Fluids
pressure, cellular edema, and cell damage.
• Document baseline data. Before infusion,
• Do not administer along with blood products. assess the patient’s vital signs, edema status,
Most hypotonic solutions can cause hemolysis of lung sounds, and heart sounds. Continue
red blood cells especially during rapid infusion of monitoring during and after the infusion.
the solution.
• Watch 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 the arms, legs, face,
shortness of breath, high blood pressure, and
discomfort on the body (e.g., headache,
cramping).
 • Monitor and observe the patient during Human Albumin
administration. Hypertonic solutions should be Uses
administered only in high acuity areas with 5% Albumin • Commonly utilized colloid solution.
constant nursing surveillance for potential • 309 mOsm/L • Used to increase the circulating
volume and restore protein levels in
complications. 25% Albumin conditions such as burns,
• 312 mOsm/L pancreatitis, and plasma loss
• Verify order. Prescription for hypertonic through plasma.
• 25% albumin is used together with
solutions should state the specific hypertonic sodium and water restriction to
fluid to be infused, the total volume to be infused, reduce excessive edema.
the infusion rate and length of time to continue • They are considered blood
transfusion products and uses the
the infusion. same protocols and nursing
precautions.
• Assess health history. Patients with kidney or
Caution
heart disease and those who are dehydrated • Contraindication in patients with the
should not receive hypertonic IV fluids. These ff conditions: severe anemia, heart
solutions can affect renal filtration mechanisms failure or known sensitivity to
albumin.
and can easily cause hypervolemia to patients
with renal or heart problems.
Low-molecular-weight Dextrans (LMWD)
• Prevent fluid overload. Ensure that Uses
administration of hypertonic fluids does not Other name: • Used to improve microcirculation in
precipitate fluid volume excess or overload. • Dextran 40 patients with poor peripheral
circulation.
• Used to treat shock related to
• Do not administer peripherally. Hypertonic vascular volume loss (burns,
solutions can cause irritation and damage to the hemorrhage, trauma and surgery)
• Used to prevent venous
blood vessel and should be administered through thromboembolism on certain
a central vascular access device inserted into a surgical procedures.
central vein.
Caution
• Contraindication in patients with
• Monitor blood glucose closely. Rapid infusion thrombocytopenia,
of hypertonic dextrose solutions can cause hypofibrinogenemia and
hypersensitivity to dextran.
hyperglycemia. Use with caution for patients with
diabetes mellitus.
High-molecular-weight Dextrans (HMWD)

2. Colloid Uses
Other name: • Used for patients with hypovolemia
• Dextran 70 and hypertension.
- Plasma expanders • Dextran 75
Caution
• Contraindication in patients with
- Contain large molecules that do not pass through hemorrhagic shock.
semipermeable membranes.
Etherified Starch
- Colloids are IV fluids that contain solutes of high Uses
molecular weight, technically, they are hypertonic Other name: • These are solutions derived from
• EloHAES Starch.
solutions, which when infused, exert an osmotic • HyperHAES • Used to increase intravascular fluid
pull of fluids from interstitial and extracellular • Voluven but can interfere with normal
spaces. coagulation.

- They are useful for expanding the intravascular
volume and raising blood pressure.
- Colloids are indicated for patients in
malnourished states and patients who cannot
tolerate large infusions of fluid.
Gelatin
Uses
• Have lower molecular weight than
dextrans and therefore remain in
the circulation for a shorter period of
time.
Plasma Protein Fraction (PPF)
Uses
• Solution that is also prepared from
plasma, and like albumin, is heated
before infusion.
• It is recommended to infuse slowly
to increase circulating volume.
Nursing Consideration for Colloid IV Solution ▪ multiple blood transfusions can result in a
decrease in the plasma calcium levels.
• Assess allergy history. Most colloids can cause
allergic reactions, although rare, so take a careful
▪ IV fat emulsion, also known as lipid emulsion, is
allergy history, asking specifically if they’ve ever
a component of parenteral nutrition for patients
had reaction to an IV infusion before.
who are unable to get nutrition through an oral
• Use a large-bore needle (18-gauge). A larger
diet.
needle is needed when administering colloid
solutions.
• Document baseline data. Before infusion,
assess the patient’s vital signs, edema status,
lung sounds, and heart sounds. Continue
monitoring during and after the infusion.
• Monitor patient’s response. Monitor intake and
output closely for signs of hypervolemia,
hypertension, dyspnea, crackles in the lungs,
and edema.
• Monitor coagulation indexes. Colloid solutions
can interfere with platelet function and increase
bleeding times, so monitor the patient’s
coagulation indexes.

3. Blood and Blood Products.

Nurses complete a thorough patient assessment before,
during, and after administration of blood products. Each
facility has a policy and procedure for blood transfusions,
and each registered nurse is oriented in the correct
procedure.

Blood products include

• packed red blood cells (PRBCs)
• plasma
• platelets, and cryoprecipitate.

A unit of PRBCs contains concentrated RBCs with most

of the plasma and platelets removed; the approximate
volume is 350 mL/unit.

The approximate volume of a unit of whole blood is 500

mL/unit. Infusing PRBCs over whole blood offers an
advantage because packed cells allow an increase in
oxygen-carrying capacity with a smaller volume.

One unit of whole blood elevates the hemoglobin by

approximately 0.5 to 1 g/dL, and one unit of PRBCs
elevates the hematocrit by three points

▪ The maximum rate of an infusion is 4 hours per

unit, beginning with removal of the unit from the
refrigerator. If the transfusion is not finished by
the 4-hour mark, the transfusion bag must be
returned to the blood bank, and a new bag
issued to complete the transfusion.
▪ Never add medications to the unit of blood.

For patients receiving multiple blood transfusions, the

serum ionized calcium level should be monitored. Both
PRBCs and whole blood products are processed using
sodium citrate and citric acid for anticoagulation.