fluid and electrolytes and acidosis and alkalosis

Aashish Parihar
Nursing Tutor
College of Nursing
AIIMS, Jodhpur

Fluid, electrolyte and
acid base balances
Content-
 Distribution and composition of body fluids.
 Movements and regulation of body fluid and electrolytes
 Regulation of acid-base balance & type of acid-base imbalance
 Type of intravenous fluid
 Measuring fluid intake and output and maintaining intake-output
charts.
 Initiating intravenous therapy.
 Regulating intravenous flow rate
 Maintenance of intravenous system
 Changing a peripheral intravenous dressing.
 Blood transfusion.
 Conditions need fluid restriction.

distribution and composition oF
body Fluids

body Fluids
 2/3 (65%) of TBW is intracellular (ICF)
 1/3 extracellular water
25 % interstitial fluid (ISF)
 5- 8 % in plasma (IVF intravascular fluid)
1- 2 % in transcellular fluids – CSF, intraocular fluids,
serous membranes.

body Fluids
 Body fluids are:
 Electrically neutral
 Osmotically maintained
 Osmolality-It is a measure of the number of particles per
kilogram of water. ( m osmoles/kg)
 Osmotic pressure is the amount of hydrostatic pressure
needed to stop the flow of water by osmosis. It is primarily
determined by the concentration of solutes.

body Fluids
Fluid in the body compartments contains mineral
salts known as electrolytes.
An electrolyte is a compound that separates into
ions (charged particles) when it dissolves in water.
Ions that are positively charged are called cations;
ions that are negatively charged are called anions.

body Fluids
Solutes and dissolved particles-
 Electrolytes –Are compounds having charged particles
Cations – positively charged ions
○ Na+, K+ , Ca++, H+
Anions – negatively charged ions
○ Cl-, HCO3
- , PO4
3-
 Non-electrolytes – Uncharged compounds.
○ Proteins, urea, glucose, O2, CO2

movements and regulation oF
body Fluid and electrolytes
 Active transport, diffusion, osmosis, and filtration are
processes that move water and electrolytes between body
compartments.
 Active transport –Active transport is the movement of all
types of molecules across a cell membrane against
its concentration gradient (from low to high concentration).
 Eg concentration of Na is high in ECF as compared to
ICF. This is done by active transport- sodium
potassium pump, keeping ICF lower in Na and higher
in ECF, otherwise sodium can easily enter ICF through
diffusion.
 It requires energy in the form of ATP

 Diffusion –passive movement of particles down a
concentration gradient (i.e from an area of higher
concentration to lower concentration.
 Osmosis – Osmosis is the spontaneous net movement
of water molecules through a
partially permeable membrane into a region of
higher solute concentration, in the direction that tends
to equalize the solute concentrations on the two sides.

 Fluid compartments are separated by membranes that
are freely permeable to water.
 Movement of fluids due to:
 hydrostatic pressure
 osmotic pressure
 Capillary filtration (hydrostatic) pressure
 Capillary colloid osmotic pressure
 Interstitial hydrostatic pressure
 Tissue colloid osmotic pressure

regulation oF acid-base balance
 For normal function of body and normal enzyme
activity a normal hydrogen ion concentration is
essential.
 pH is the negative log of hydrogen ion concentration.
 A hydrogen ion is the single free proton release from
hydrogen atom.
 Normal Hydrogen ion of arterial blood is =
0.00004meq/l which is equal to pH 7.4.

 pH of arterial blood is 7.4
 pH of venous blood 7.35
 Intracellular pH is slightly lower than plasma pH
 pH of urine is 4.5-8.0
 Acidosis is the pH of body fluid is less than normal pH
 Alkalosis is the pH of the body fluid more than the
normal.

 Acids are molecules that release hydrogen ion in
solution.
 Strong acids dissociates rapidly and release large
amount of hydrogen ion .
 Weak acids have less tendency to dissociate and release
less amount of hydrogen ion

Defence against change in pH
 Buffer system of our body
 Respiratory system of our body
 Renal control of our body

 Buffer system of our body
Buffers are pairs of chemicals that work together to
maintain normal pH of body fluids
Important buffers include bicarbonate buffer, hemoglobin,
protein buffer, phosphate buffer, cellular and bone
buffer.
Buffer normally keep the blood from becoming too acid
when acids that are produced by cells circulate to the
lungs and kidneys for excretion

 Respiratory system of our body
Act with in few min (3-12 min.)
Control pH by altering co2 elimination from body by
lungs
Increased blood PCO2 and hydrogen ion stimulates
respiratory center so increase the rate and depth of
respiration

 Renal control of our body
By excreting acidic and basic urine
Relatively slow to response
Most powerful acid/base regulation system

type oF intravenous Fluid
 Following are the criteria for categorizing the IV
Fluids-
1. Molecular size and weight
2. Tonicity

Type of inTravenous fluid
 Tonicity-Tonicity is the effective osmolality and is
equal to the sum of the concentrations of the solutes
which have the capacity to exert an osmotic force
across the membrane.
 The particles which does not move across the cell
membranes easily determines the tonicity of a
fluid.

 On the basis of tonicity there are three types of IV
fluids-
 Isotonic- A fluid with same concentration of
particles as normal blood is called isotonic.
 Hypertonic – more concentrated than blood
 Hypotonic- less concentrated than blood.

Isotonic fluid
 Solution has the same solute concentration (or
osmolality) as normal blood plasma (290mOsm)
and other body fluids
 Solution stays where it is infused, inside the blood
vessel
 Expands the intravascular compartment
 Does not affect the size of the cells
 Solution maintains body fluid balance

Isotonic fluid

Isotonic fluid
 These fluids remain intravascular momentarily, thus
expanding the volume.
 Helpful with patients who are hypotensive or
hypovolemic.
 Risk of fluid overloading exists.
 Therefore, be careful in patients with left
ventricular dysfunction, history of CHF or
hypertension.

Hypotonic fluid
 Less osmolarity than serum (meaning: less sodium ion
concentration than serum)
 These fluids DILUTE serum thus decreasing
osmolarity.
 Water moves from the vascular compartment into the
interstitial fluid compartment  interstitial fluid
becomes diluted osmolarity decreases  water is
drawn into adjacent cells.
 Less than 10% remain intravascular, inadequate for
fluid resuscitation
 Caution with use because sudden fluid shifts from the
intravascular space to cells can cause cardiovascular
collapse and increased ICP in certain patients.

Hypotonic fluid

Hypotonic fluid
 Solution has a lower osmolarity than serum (less
than 240 mOsm/L)
 Solution causes a fluid shift out of the blood vessels
into the cells and interstitial spaces
Solution hydrates cells while reducing fluid in the
circulatory system
 Ex.: ½ NSS (0.45% NaCl)

Hypotonic fluid
 Administer cautiously
 Solution can lower blood pressure
 Do not give if these solutions if the patient is at risk
for:
 ICP from cerebro-vascular accident
 Head trauma
 Neurosurgery

Hypertonic fluid
 Solution has an osmolarity higher than
serum(>340mOsm/L)
 Causes the solute concentration of the serum to
increase pulling fluid from the cells and the
interstitial compartment into the blood vessels
 Reduces the risk of edema, stabilizes blood
pressure, and regulates urine output

Hypertonic fluid

Hypertonic fluid
 Monitor patient for circulatory overload
 Solution can be irritating to the vein
 Useful for stabilizing blood pressure, increasing
urine output, correcting hypotonic hyponatremia
and decreasing edema.
 These can be dangerous in the setting of cell
dehydration.

Types of IV fluid on the basis of molecular size and
weight-
 Crystalloid
 colloid

Crystalloid fluid
 Clear solutions –fluids- made up of water & electrolyte
solutions; small molecules.
 These fluids are good for volume expansion.
 However, both water & electrolytes will cross a semi-permeable
membrane into the interstitial space and
achieve equilibrium in 2-3 hours.
 Remember: 3mL of isotonic crystalloid solution are
needed to replace 1mL of patient blood.
 This is because approximately 2/3rds of the solution
will leave the vascular space in approx. 1 hour.

Crystalloid fluid
 Advantages:
Inexpensive
Easy to store with long shelf life
Readily available with a very low incidence of
adverse reactions
Variety of formulations available that are effective
for use as replacement fluids or maintenance fluids
 A major disadvantage is that it takes approximately 2-3
x volume of a crystalloid to cause the same
intravascular expansion as a single volume of colloid.

Colloid fluid
 Colloids are large molecular weight solutions (nominally
MW > 30,000 Daltons)
 Macromolecular substances made of gelatinous solutions
which have particles suspended in solution and do NOT
readily cross semi-permeable membranes or form sediments.
 Their high osmolarity, are important in capillary fluid
dynamics because they are the only constituents which are
effective at exerting an osmotic force across the wall of the
capillaries.
 These work well in reducing edema  draw fluid from the
interstitial and intracellular compartments into the vascular
compartments.
 Initially these fluids stay almost entirely in the intravascular
space for a prolonged period of time compared to
crystalloids.

Colloid fluid
The general problems with colloid solutions are:
 Much higher cost than crystalloid solutions
 Small but significant incidence of adverse reactions
 Gelatinous properties  cause platelet dysfunction and
interfere with fibrinolysis and coagulation factors thus
possibly causing Coagulopathy in large volumes.
 These fluids can cause dramatic fluid shifts which can
be dangerous if they are not administered in a
controlled setting.

Colloid fluid
 Dextran
-Polysaccharide fluid
 Albumin
-Natural plasma protein from donor plasma
 Mannitol
-Sugar alcohol substance
 Hetastarch
-Synthetic colloid made from starch

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SSoolluuttiioonnss VVoolluummeess NNaa++ KK++ CCaa22++ MMgg22++ CCll-- HHCCOO33
-- DDeexxttrroossee mmOOssmm//LL
EECCFF 142 4 5 103 27 280-310
LLaaccttaatteedd
RRiinnggeerr’’ss 130 4 3 109 28 273
00..99%% NNaaCCll 154 154 308
00..4455%%
NNaaCCll 77 77 154
DD55WW 50
DD55//00..4455%%
NNaaCCll 77 77 50 406
33%% NNaaCCll 513 513 1026
66%%
HHeettaassttaarrcchh 500 154 154 310
55%%
AAllbbuummiinn 250,500 130-
160 <2.5 130-
160 330
2255%%
AAllbbuummiinn 20,50,100 130-
160 <2.5 130-
160 330

Measuring fluid inTake and ouTpuT
 Fluid and electrolyte homeostasis is maintained in
the body
 Neutral balance: input = output
 Positive balance: input > output
 Negative balance: input < output

Intake and Output
 Defines as the measurement and recording of all fluid
intake and output during a 24 – hour period provides
important data about the client's fluid and electrolyte
balance.
 Unit of measurement of intake and output is mL
(milliliter).
 To measure fluid intake, nurses convert household
measures such as glass, cup, or soup bowl to metric
units.
 Gauge fluid balance and give valuable information
about your patient's condition.

Need –
 It helps us determine the patient’s fluid status:
 1. Are they Hydrated?
 2. Are they Dehydrated?
 3. Are they in Fluid Overload?
 4. Is there an obstruction?

Intake
1. Oral Fluids: Water, Ice, Beverages
2. Semi-Liquid Foods: Pudding, Jell-O, Custards,
Yogurt
3. Parenteral Fluids: IV Fluid, Medications, Blood
Products
4. Any Food Liquid at Room Temperature:
Popsicles, ice cream, and frozen yogurt
8. Tube feedings
9. Catheter or tube irrigants

Output
 Urine
 Vomitus and liquid feces
 Tube drainage
 Wound drainage and draining fistulas

Measurement of Volume
 1 tablespoon (tbsp) = 15 milliliters(ml)
 3 teaspoons(tsp) = 15 milliliters(ml)
 1 cup(C) = 240 milliliters(ml)
 8 ounces(oz) = 240 milliliters(ml)
 1 teaspoon(tsp) = 5 milliliters(ml)
 1 cup(C) = 8 ounces(oz)
 16 ounces(oz) = 1 pound(lb)
 1 ounce (oz) = 30milliliters(ml)

DOs
 Identify whether your patient has undergone
surgery or if he has a medical condition or takes
medication that can affect fluid intake or loss.
 Measure and record all intake and output. If you
delegate this task, make sure you know the totals
and the fluid sources.
 At least every 8 hours, record the type and amount
of all fluids he's received and describe the route as
oral, parenteral, rectal, or by enteric tube.

DOs
 Record ice chips as fluid at approximately half their
volume.
 Record the type and amount of all fluids the patient
has lost and the route.
 Describe them as urine, liquid stool, vomitus, tube
drainage and any fluid aspirated from a body cavity.
 If irrigating a nasogastric or another tube or the
bladder, measure the amount instilled and subtract it
from total output.

DOs
 For an accurate measurement, keep toilet paper out
of your patient's urine.
 Measure drainage in a calibrated container.
 Observe it eye level and take the reading at the
bottom of the meniscus.
 Evaluate patterns and values outside the normal
range, keeping in mind the typical 24 – hour intake
and output.

DOs
 When looking at 8 – hour urine output, ask how
many times the patient voided, to identify
problems.
 Regard intake and output holistically because age,
diagnosis, medical problem, and type of surgical
procedure can affect the amounts. Evaluate trends
over 24 to 48 hours.

DONTs
 Don't delegate the task of recording intake and
output until you're sure the person who's going to
do it understands its importance.
 Don't assess output by amount only. Consider color,
color changes, and odor too.
 Don't use the same graduated container for more
than one patient.

MainTaining inTake-ouTpuT charTs

inTravenous Therapy
(inTravenous infusion)
Definition
Introduction of large amount of fluid into body
via veins is termed as intravenous infusion.

inTravenous Therapy
Purposes
 To restore the fluid volume that is lost from the
body due to hemorrhage, vomiting, diarrhea,
drainage etc.
 To meet the patient’s basic requirement for calories,
minerals, water and vitamins.
 To prevent and treat shock and collapse.
 To administer medicines.
 To supply adequate amount of fluid, electrolytes
and nutrients when patient is unable to take orally
or when contraindicated orally.

inTravenous Therapy
Indications
 Hemorrhage, shock, extensive burns etc.
 Prolonged nausea, vomiting, peritonitis, paralytic
ileus, fistulas etc.
 Toxemias and septicemias
 When intestinal tract is not intact
 To administer medications which can be destroyed
by the gastric juices.

inTravenous Therapy
Solutions used
 Nutrient solutions
 Electrolyte solutions
 Plasma expanders
 Acidifying or alkalinizing solutions

intravenous therapy
(intravenous infusion)
General instructions for IV infusion
 Follow strict aseptic technique
 Fluid should be administered only with clearly
written order. The order should include type of
solution, concentration, amount to be administered
and total time of infusion.
 Maintain the specified rate of flow to prevent the
circulatory overload.
 During infusion observe the patient for any
unfavorable symptoms and if found report
immediately.

intravenous therapy
 Following observations should be made throughout the
infusion-
 Flow rate, dislodgment of needle
 Signs of circulatory overload
 Urine out put
 Infusion site for infiltration and thrombophlebitis
 Fluid level in the bottle
 Patency of the IV tubing
 Intake and output chart
 Regular estimation of electrolytes in blood.

intravenous therapy
 When electrolytes are used, flow rate should be slow.
 Always check the expiry date before opening the IV bottle
 Any suspended articles in IV bottles, discolored or cloudy
fluid should not be used for infusion.
 Make sure that drip set is sterile and in good working
condition
 Select a proper site for IV infusion
 Never allow the bottle to get empty completely to prevent the
entry of the air into tissues.
 Fluid should always be administered at body temperature.
 Monitor the vital sign at regular intervals

intravenous therapy
Complication of IV infusion
 Circulatory overload
 Infiltration
 Damage to the walls of blood vessels and extravasation of blood
(hematoma)
 Thrombophlebitis
 Pyrogenic reactions
 Air embolism
 Infection at the needle site
 Allergic reaction
 Serum hepatitis
 Osmotic diuresis
 Nerve damage

intravenous therapy
 Circulatory overload means that the intravascular fluid
compartment contains more fluid than the normal.
 It occurs due to rapid administration of fluid or the fluid
administered is more than requirement.
 Circulatory overload results in cardiac failure and
pulmonary edema
 Signs of pulmonary edema include dyspnoea, cough, red
frothy sputum, gurgling sounds on respiration etc.
 Puffiness of the face, generalized edema and engorged neck
veins indicate the cardiac failure.

intravenous therapy
 Circulatory overload can be prevented by carefully
regulating the flow rate over 24 hours.
 Flow rate can be calculated with the following formula-
Flow rate= total volume infused (ml)×drops/ml
total time of the infusion in minutes

intravenous therapy
 Infiltration
 Infiltration is the escape of fluid into the subcutaneous tissues due to
dislodgment of needle.
 Following sign and symptoms indicate the infiltration-
 Infusion rate slows or stops completely
 Development of swelling, hardness, and pain around the injection
site
 Feeling of numbness and coolness around the injection site
 Failure of blood to return to the tubing when the bottle is lowered

intravenous therapy
 Infiltration
 When infiltration has taken place, stop the infusion
immediately and apply warm compress over the side of
infusion and restart the infusion at another site

intravenous therapy
 Damage to the walls of the blood vessels and extravasation of
blood (hematoma)
 Walls of the blood vessels may be damaged due to careless
introduction of the needle into body.
 The needle may puncture the blood vessels in more than one place
and the blood may flow into the tissues
 It causes the hematoma (swelling) formation at the site of the
puncture
 To treat the hematoma withdraw the needle immediately and apply
pressure to the control bleeding
 Apply cold compress over the injured site

intravenous therapy
 Thrombophlebitis
 Thrombophlebitis is caused by mechanical
trauma to the vein or the chemical irritations of
some substances introduced into the veins such
as KCl.
 With thrombophlebitis patient may complaints of
burning pain along the vein
 Nurse may observe the redness, swelling, and
increased skin temperature over the vein
 General symptoms such as fever, rapid pulse
malaise etc. may occur
 Treatment includes- stop IV fluid, restart at
another site, apply warm moist compress, do not
massage or rub the area because it may dislodge
the clot and may lead to pulmonary embolism.

intravenous therapy
 Pyrogenic reaction
 It occurs in 30 minutes after the infusion.
 Characterized by fever, chills, headache, nausea, vomiting, and
circulatory collapse in severe cases.
 Pyrogenic reactions usually caused by pyrogens present in the
IV fluids or due to the contaminated IV tubing and needles used
for infusion.
 Prevention of pyrogenic reaction-
 Check the IV fluids in good light before they are infused
 Any solution that is cloudy or containing suspended particles or
with a color change should not be used
 Use sterile needle and tubing for infusion

intravenous therapy
 Pyrogenic reaction
 Treatment of pyrogenic reaction-
 Stop the infusion immediately
 Change the IV fluid and tubing
 Administer anti-allergic drugs
 Apply cold therapy to lower the body temperature
 Restart the IV infusion

intravenous therapy
 Air embolism
 An air embolism is an air bubble trapped in a blood vessel.
 As a result tissues will not receive adequate oxygen.
 Pulmonary embolism characterized by-
 Dyspnoea
 Cyanosis
 Low blood pressure
 Shock
 Tachycardia
 Unconsciousness

intravenous therapy
 Air embolism
 Prevention of air embolism-
 Expelled air completely from the tubing and the needle
before introducing the needle into the vein.
 Do not elevate the arm or leg receiving the infusion above
the level of heart.
 Never allow the IV drip to run dry
 There should be a little fluid left in the tubing when the
infusion is discontinued.

intravenous therapy
 Air embolism
 Management of air embolism-
 Pulmonary embolism is a life threatening condition which
should be treated intensively
 Monitor the vital signs regularly
 Stop the fluid

intravenous therapy
 Infection at the needle site-
 The needle may become contaminated during insertion or
infection may occur at the needle site when it is left
exposed for a long period
 Prevention of infection-
 Follow strict aseptic technique during procedure
 Cover the needle with sterile dressing.

intravenous therapy
 Allergic reaction-
 This may be due certain type of medications administered
with IV fluids.
 Serum hepatitis-
 Infectious hepatitis have been attributed to improperly
disinfected syringes and needles.
 inoculation of .0004 ml of infected blood may transmit the
serum hepatitis.

intravenous therapy
 Osmotic diuresis-
 If dextrose solution is administered too rapidly the patient may
develop glucose overload and as a result excessive diuresis will
take place
 If diuresis remains unchecked extreme dehydration followed by
shock and collapse will ensure
 To prevent osmotic diuresis-
 Observe vital sign frequently
 Monitor urine out put
 Assess the body weight
 Frequently monitor the urine for acetone and sugar
 Nerve damage-
 Nerve damage may occur from tying the arm too tight with the
splint.

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