PHARMACOLOGY FLUID VOLUME AND ELECTROLYTES

1st SEMESTER MIDTERM S.Y. 2023-2024 PROFESSOR: MS. ADA MAGNAYON

HOMEOSTATIS Electrolyte Concentration in Body

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

Fluid and Electrolyte Movement

FLUID COMPART MENTS
⋆The body cells- Nutrients and oxygen should
⋆ Intracellular fluid (ICF) - is contained
enter body cells while waste products should
within the body's cells.
exit the body.
⋆ Extracellular fluid (ECF)- comprises the
⋆ The cell membrane- The cell membrane
fluid outside of the cells.
separates the Intracellular environment from
The ECF is further divided into three sub-
the extracellular environment.
compartments:
⋆ Permeability- The ability of a membrane to
Interstitial compartment- bathes and surrounds
allow molecules to pass through is known as
the tissue cells.
permeability.
Intravascular compartment- contains the
• Freely permeable membranes- These
plasma and blood vessels;
membranes allow almost any food or waste
Transcellular compartment- also known as the
substance to pass through.
third-space, contains mucus and
• Selectively permeable- The cell membrane
gastrointestinal (GI). cerebrospinal,
is selectively permeable, meaning that each
pericardial, synovial, and ocular fluids.
cell's membrane allows only certain specific
substances to pass through.
ANIONS AND CATIONS
• Electrolytes are substances that separate or PASSIVE TRANSPORT
dissociate into ions (charged particles) in
solution, and they are abundant in both ICF ⋆ Diffusion- movement of molecules from an
and ECF area of high concentration to one of low
⋆ Cation - positive charge concentration.
⋆ Anion - negative charge ⋆ Osmosis - the movement of water across a
semipermeable membrane from areas of low
Cations Anions solute concentration to those of high solute
Potassium (K+ ) Chloride (Cl-) concentration
Sodium (Na+) Bicarbonate (HCO3-) ⋆ Hydrostatic Pressure - the force within a
Calcium (Ca2+) Phosphate (PO4-) fluid compartment
Magnesium (Mg2+) Sulfate (SO4-) ⋆ Filtration- is the transport of water and
dissolved materials concentration already
exists in the cell.

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ACTIVE TRANSPORT
⋆ Solutes move from an area of lower
concentration to an area of higher
concentration. Like fish swimming upstream,
active transport requires energy to make it
happen.
⋆ Active transport mechanisms require
specific enzymes and energy expenditure in
the form of adenosine triphosphate (ATP).
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 also is a measure of the concentration of
solutes per kilogram in urine.
⋆ Normal serum osmolality ranges from 275
to 295 mOsm/kg.
TYPES OF F LUID C ON C EN TRA TION
A R E BA SED ON THE OSMOLA LITY OF
BOD Y FLUID S
⋆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
fluid compartment, in replacing electrolyte
losses, and in administering medications and
blood products.
⋆ Intravenous fluids (IV Fluids), also
known as intravenous solutions, are
supplemental fluids used in intravenous
therapy to restore or maintain normal fluid
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volume and electrolyte balance when the oral
route is not possible.
IV SOLUTIONS CAN ALSO BE CLASSIFIED
BASED ON THEIR PURPOSE
⋆ 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- contain 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
CRYSTALLOID SOLUTIONS
⋆Contains fluids and electrolytes and freely
crosses 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.
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⋆Crystalloids are used as short-term ISOTONIC SOLUTION

maintenance fluids and to treat dehydration
and electrolyte imbalances. Normal Saline Solution (NSS) (0.9% NaCl)
Osmolality Uses
⋆ Crystalloids cause early plasma expansion
⋆ 308 mOsm/L ⋆ Isotonic solution of choice for
but have a shorter duration of action than expanding ECF volume.
colloid solutions. Contains: ⋆ Infused to correct ECF deficit
⋆ Water ⋆Used alongside administration of
⋆ Sodium (154 blood products
T H R EE MA JOR C LASSIFIC A TION S OF meq/L) ⋆ Used to replace large sodium loss
C R YSTA LLOID ⋆ Chloride (154 such as burn injuries and trauma
meq/L)
ISOTONIC Caution
Should not be used for patients
with heart failure, pulmonary
Isotonic fluids, such as normal saline solution, edema, and renal impairment
have a concentration of dissolved particles, or
tonicity, equal to that of intracellular fluid Dextrose 5% in Water (D5W)
(ICF). Osmotic pressure is therefore the same Osmolality Uses
⋆ 252 mOsm/L ⋆ Initially isotonic and provides
inside and outside the cells, so they neither free water when dextrose is
shrink nor swell with fluid movement. Contains: metabolized.
HYPERTONIC ⋆ Water ⋆ Expands ECF and ICF, helpful in
⋆ Glucose (50g/l) rehydrating and excretory process.
⋆ Used to treat hypernatremia.
Hypertonic fluid has a tonicity greater than that
of ICF, so osmotic pressure is unequal inside Caution
⋆ Should not be used for fluid
and outside the cells. Dehydration or a rapidly resuscitation because it may cause
infused hypertonic fluid, such as 3% saline or hyperglycemia. Should be avoided
50% dextrose, draws water out of the cells into with patients at risk for increased
ICP
the more highly concentrated extracellular
fluid (ECF).
NURSING CONSIDERATIONS FOR
HYPOTONIC
ISOTONIC IV SOLUTIONS
Hypotonic fluids, such as half-normal saline
⋆ Document baseline data. Before infusion,
solution, have a tonicity less than that of ICF,
assess the patient's vital signs, edema status,
so osmotic pressure draws water into the cells
lung sounds, and heart sounds. Continue
from the ECF. Severe electrolyte losses or
monitoring during and after the infusion.
inappropriate use of I.V. fluids can make
⋆ Observe for signs of fluid overload. Look
body fluids hypotonic.
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.

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⋆ Prevent hypervolemia. Patients being D10 % Water (D10W)

treated for hypovolemia can quickly develop Osmolality Uses
⋆ 505 mOsm/L ⋆ Used in the treatment of ketosis
fluid overload following rapid or over-infusion of starvation and provides calories
of isotonic IV fluids. Contains: and free water
⋆ Elevate the head of the bed at 35 to 45 ⋆ Water
degrees. Unless contraindicated, position the ⋆ Glucose 100g/L Caution
⋆ 380 kcal/L ⋆ Should be administered in
client in a semi-Fowler’s position. central line as possible.
⋆ Elevate the patient’s legs. If edema is ⋆ Do not infuse using the same
present, elevate the legs of the patient to line as blood products as it can
cause RBC hemolysis
promote venous return.
⋆ Educate patients and families. Teach
patients and families to recognize signs and D50 % Water (D50W)
symptoms of fluid volume overload. Instruct Osmolality Uses
patients to notify their nurse if they have ⋆ 2523 mOsm/L ⋆ Used to treat severe
hypoglycemia
trouble breathing or notice any swelling. Contains: ⋆ Administer rapidly via IV
⋆ Close monitoring for patients with heart ⋆ Water bolus
failure. Because isotonic fluids expand the ⋆ Glucose 500g/L
intravascular space, patients with hypertension
and heart failure should be carefully monitored
for signs of fluid overload. NURSING CONSIDERATIONS FOR
HYPERTONIC IV SOLUTIONS
HYPERTONIC SOLUTION
⋆ Document baseline data. Before infusion,
Hypertonic Sodium Chloride Solution
assess the patient’s vital signs, edema status,
3% NaCl Uses
⋆ Sodium (513 ⋆ Used In the acute treatment of lung sounds, and heart sounds. Continue
meq/L) severe hyponatremia and should be monitoring during and after the infusion.
⋆ Chloride (513 only used in critical situations to ⋆ Watch for signs of hypervolemia. Since
meq/L) treat hyponatremia
⋆ 1030 mOsm/L ⋆ Used in patients with cerebral hypertonic solutions move fluid from the ICF
edema to the ECF, they increase the extracellular fluid
5% NaCl ⋆ Some patients may need diuretics volume and increases the risk for
to assist in fluid excretion
⋆ Sodium (855 hypervolemia. Look for signs of swelling in
meq/L) Caution arms, legs, face, shortness of breath, high
⋆ Chloride (855 ⋆ Should be Infused at a very low blood pressure, and discomfort in the body
meq/L) rate to avoid the risk of pulmonary
⋆ 1710 mOsm/L edema (e.g., headache, cramping).
⋆ If administered in large ⋆ Monitor and observe the patient during
quantities and rapidly, they may administration. Hypertonic solutions should
cause ECF excess and circulatory
overload
be administered only in high acuity areas with
Sen constant nursing surveillance for potential
complications.
⋆ Verify order. Prescription for hypertonic
solutions should state the specific hypertonic
fluid to be infused, the total volume to be
infused, the infusion rate and the length of time
to continue the infusion.

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⋆ Assess health history. Patients with kidney ⋆ Glucose (50

g/L)
or heart disease and those who are dehydrated
⋆ 170 kcal/L
should not receive hypertonic IV fluids. These
solutions can affect renal filtration
mechanisms and can easily cause
hypervolemia to patients with renal or heart Ringer’s Solution
problems. Osmolality Uses
⋆ 273 mOsm/L ⋆ Used to correct dehydration,
⋆Prevent fluid overload. Ensure that sodium depletion and replace GI
administration of hypertonic fluids does not Contains: tract fluid loses
precipitate fluid volume excess or overload. ⋆ Water ⋆ Also used in fluid losses caused
⋆ Sodium by burns, fistula drainage and
⋆Do not administer peripherally. Hypertonic (130meq/L) trauma.
solutions can cause irritation and damage to Potassium ⋆Often administered to patients
the blood vessel and should be administered (4meq/L) with metabolic acidosis because
⋆ Calcium it is an alkalizing solution
through a central vascular access device (3meq/L) Caution
inserted into a central vein. ⋆ Chloride ⋆ Used in caution for patients
⋆Monitor blood glucose closely. Rapid (109meq/L) with heart failure and renal
infusion of hypertonic dextrose solutions can failure
cause hyperglycemia. Use with caution for
patients with diabetes mellitus.
NURSING CONSIDERATIONS FOR
HYPOT ONIC SOLUTION HYPOTONIC IV SOLUTIONS

0.45% Sodium Chloride Solution (0.45% ⋆ Document baseline data. Before infusion,
NaCl) assess the patient’s vital signs, edema status,
Osmolality Uses
⋆ 154 mOsm/L ⋆ Used for replacing water in lung sounds, and heart sounds. Continue
patients who have hypovolemia monitoring during and after the infusion.
Contains: with hypernatremia ⋆Do not administer in contraindicated
⋆ Water
⋆ Sodium Caution
conditions. Hypotonic solutions may
(77meq/L) ⋆ Excessive use may lead to exacerbate existing hypovolemia and
⋆ Chloride hyponatremia due to dilution of hypotension causing cardiovascular collapse.
(77meq/L) sodium Avoid use in patients with liver disease,
trauma, or burns.
⋆Risk for increased intracranial pressure
0.33% Sodium Chloride Solution (0.33% (IICP). Should not be given to patients with
NaCl) risk for IICP as the fluid shift may cause
Osmolality Uses cerebral edema (remember: hypotonic
⋆ 363 mOsm/L ⋆ Used to allow kidneys to retain solutions make cells swell).
(hypotonic one needed amounts of water. Free
dextrose is water helps kidneys eliminate ⋆ Monitor for manifestations of fluid volume
metabolized) Solutes deficit. Signs and symptoms include confusion
⋆ Typically administered with in older adults. Instruct patients to inform the
Contains: dextrose to increase tonicity
⋆ Water Caution nurse if they feel dizzy.
⋆ Sodium ⋆ Used in caution for patients ⋆Warning on excessive infusion. Excessive
(56meq/L) with heart failure and renal infusion of hypotonic IV fluids can lead to
⋆Chloride insufficiency
(56meq/L) intravascular fluid depletion, decreased blood
pressure, cellular edema, and cell damage.
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⋆ Do not administer along with blood

products. Most hypotonic solutions can cause Low-molecular-weight Dextrans (LMWD)
hemolysis of red blood cells, especially during Uses
⋆Used to improve
rapid infusion of the solution.
Other name microcirculation in patients
⋆ Dextran 40 with poor peripheral circulation
COLLOID ⋆ Used to treat shock related to
vascular volume loss (burns,
hemorrhage, trauma and
⋆ Plasma expanders contain large molecules surgery)
that do not pass through semipermeable ⋆Used to prevent venous
membranes. thromboembolism on certain
⋆ Colloids are IV fluids that contain solutes of surgical procedures

high molecular weight, technically, they are Caution

hypertonic solutions, which when infused,
exert an osmotic pull of fluids from interstitial
and extracellular spaces.
⋆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.
HUMAN ALBUMIN
Human Albumin
5% Albumin Uses
⋆ 309 mOsm/L ⋆ Commonly utilized colloid
solution
25% Albumin ⋆ Used to increase the
⋆ 312 mOsm/L circulating volume and restore
protein levels in conditions such
as burns, pancreatitis and
plasma loss through plasma
⋆ 25% albumin is used together
with sodium and water restriction
to reduce excessive edema.
⋆ They are considered blood
transfusion products and use the
same protocols and nursing
precautions
Caution
⋆ Contraindication in patients with
ff conditions: severe anemia, heart
failure or known sensitivity o
albumin.
⋆ Contraindication in patients
with thrombocytopenia,
hypofibrinogenemia and
hypersensitivity to dextran
High-molecular-weight Dextrans (HMWD)
Other name Uses
⋆ Dextran 70 ⋆ Used for patients with
⋆ Dextran 75 hypovolemia and hypertension
Caution
Caution
⋆ Contraindication in patients
with hemorrhagic shock
Etherified Starch
Other name Uses
⋆ These are solution derived from
⋆EloHAES Starch
⋆HyperHAES ⋆Used to increase intravascular
⋆Voluven fluid but can interfere with
normal coagulation
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.

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NURSING CONSIDERATIONS FOR COLLOID
IV SOLUTIONS
⋆ Assess allergy history. Most colloids can
cause allergic reactions, although rare, so take
a careful allergy history, asking specifically if
they’ve ever had a reaction to an IV infusion
before.
⋆Use a large-bore needle (18-gauge). A
larger 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 the 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.
BLOOD A ND BLOOD PRODUCTS
⋆ A blood productis any therapeutic substance
derived from human blood, including whole
blood and other blood components for
transfusion, and plasma-derived medicinal
products.
⋆ Blood and blood products consist of whole
blood, packed red blood cells, plasma, and
albumin.
BLOOD PRODUCT S
⋆ Whole blood
⋆ Platelets
⋆ Packed red blood cells
⋆ Fresh frozen plasma
⋆ Immune globulins
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WHOLE BLOOD TRANSFUSION
⋆ Generally indicated only for patients who
need both increased oxygen-carrying capacity
and restoration of blood volume when there is
no time to prepare or obtain the specific blood
components needed.
PLATELETS
⋆ Administer as rapidly as tolerated (usually 4
units every 30 to 60 minutes). Each unit of
platelets should raise the recipient’s platelet
count by 6000 to 10,000/mm3: however, poor
incremental increases occur with
alloimmunization from previous transfusions,
bleeding, fever, infection, autoimmune
destruction, and hypertension.
PACKED RED BLOOD CELLS
⋆ Should be transfused over 2 to 3 hours; if
patient cannot tolerate volume over a
maximum of 4 hours, it may be necessary for
the blood bank to divide a unit into smaller
volumes, providing proper refrigeration of
remaining blood until needed. One unit of
packed red cells should raise hemoglobin
approximately 1%, hemactocrit 3%.
PLASMA
⋆ Because plasma carries a risk of hepatitis
equal to that of whole blood, if only volume
expansion is required, other colloids (e.g.,
albumin) or electrolyte solutions (e.g.,
Ringer’s lactate) are preferred. Fresh frozen
plasma should be administered as rapidly as
tolerated because coagulation factors become
unstable after thawing
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