This document discusses oral and intravenous fluid and electrolyte replacement. Oral rehydration solutions containing water, potassium, sodium and glucose can correct mild deficits, while IV therapy is needed to treat more severe imbalances. IV solutions are classified as hypotonic, isotonic or hypertonic based on their tonicity. Central venous access devices like central lines and ports provide long-term IV access but carry infection risks requiring strict sterile technique for dressings and flushing.

1. ORAL FLUID AND ELECTROLYTE REPLACEMENT
•Oral rehydration solutions containing water, potassium, sodium
and glucose may be used to correct mild fluid & electrolyte
deficits
Glucose not only provides calories but also promotes sodium
and water absorption in the small intestine
•Cola drinks are avoided because they do not contain adequate
electrolyte replacement & sugar content may lead to osmotic
diuresis

2. IV FLUID AND ELECTROLYTE REPLACEMENT
• IV fluid and electrolyte therapy is necessary to treat many different fluid
& electrolyte imbalances
Many patients need maintenance IV fluid therapy while they cannot
take oral fluids (e.g. during and after surgery)
Other patients need corrective or replacement therapy for losses that
have already occurred
• Amount and type of solution are determined by the normal daily
maintenance requirements & by imbalances identified by laboratory
results
• IV replacement solutions are classified by their concentration or tonicity
Tonicity is an important factor in determining the appropriate solution
to correct water and solute imbalances

3. IV FLUID AND ELECTROLYTE REPLACEMENT
• Hypotonic IV Fluids
A hypotonic solution provides more water than electrolytes (dilutes the
ECF)
Water moves from ECF to ICF via osmosis
ICF and ECF will have the same osmolality after achieving osmotic
equilibrium (both compartments are expanded)
Maintenance fluids are usually hypotonic solutions (e.g. 0.45% NaCl)
because normal daily losses are hypotonic
Additional electrolytes (e.g. KCl) may be added to maintain normal
levels
Hypotonic solutions have the potential to cause cellular swelling
Monitor patients for changes in mentation that may indicate cerebral
edema

4. IV FLUID AND ELECTROLYTE REPLACEMENT
•Hypotonic IV Fluids
5% dextrose in water
Dextrose is quickly metabolized
Net result is administration of free water (hypotonic) with
proportionately equal expansion of ECF & ICF
1L of 5% dextrose solution provides 50g of dextrose (170
calories)
Helps prevent ketosis associated with starvation

5. IV FLUID AND ELECTROLYTE REPLACEMENT
• Isotonic IV Fluids
Administration of an isotonic solution expands only ECF
There is no net loss or gain from ICF
An isotonic solution is ideal fluid replacement for a patient with an
ECF volume deficit
Examples of isotonic solutions include lactated Ringer’s solution & 0.9%
NaCl
Lactated Ringer’s solution - contains sodium, potassium, chloride,
calcium and lactate (the precursor of bicarbonate) in about the same
concentrations as those of ECF
It is contraindicated in patients with hyperkalemia & lactic acidosis
(associated with a decreased ability to convert lactate to bicarbonate)

6. IV FLUID AND ELECTROLYTE REPLACEMENT
Isotonic saline (0.9% NaCl) - has a sodium concentration (154
mEq/L) higher than that of plasma (135 to 145 mEq/L) and a
chloride concentration (154 mEq/L) significantly higher than
the plasma chloride level (96 to 106 mEq/L)
Excessive administration of isotonic saline can result in elevated
sodium and chloride levels
Isotonic saline may be used when a patient has experienced
both fluid and sodium losses or as vascular fluid replacement
in hypovolemic shock

7. IV FLUID AND ELECTROLYTE REPLACEMENT
• Hypertonic IV Fluid
A hypertonic solution initially raises the osmolality of ECF & expands it
Higher osmotic pressure draws water out of the cells into ECF
Useful in the treatment of hypovolemia & hyponatremia
Hypertonic solutions require frequent monitoring of BP, lung sounds and
serum sodium levels because of the risk for intravascular fluid volume excess
Concentrated dextrose and water solutions (10% dextrose or greater) are
hypertonic solutions
Dextrose is metabolized and the net result is the administration of water
The free water provided by these solutions ultimately expands both ECF
and ICF
The primary use of these solutions is the provision of calories as part of
parenteral nutrition

8. IV FLUID AND ELECTROLYTE REPLACEMENT
•Parenteral nutrition
Composed of concentrated dextrose solutions with amino
acids, electrolytes, vitamins & trace elements
•Solutions containing 10% dextrose or less can be administered
through a peripheral line
•A central line is (however) recommended to administer
solutions with concentrations greater than 10% dextrose

9. IV FLUID AND ELECTROLYTE REPLACEMENT
•Intravenous Additives
A basic solution typically provide water, electrolytes and a
minimum amount of calories
Additives are used to replace specific losses e.g. KCl, CaCl,
MgSO4, HCO3
−

10. IV FLUID AND ELECTROLYTE REPLACEMENT
• Plasma Expanders
Plasma expanders stay in the vascular space and increase the
osmotic pressure
Plasma expanders include colloids, dextran and hetastarch
Colloids are protein solutions such as plasma, albumin &
commercial plasmas
Albumin is available in 5% and 25% solutions
The 5% solution has an albumin concentration similar to that of
plasma (results in plasma volume expansion equal to the volume
infused)
Makes the 5% concentration useful in treating hypovolemic
patients

11. IV FLUID AND ELECTROLYTE REPLACEMENT
25% albumin solution is hypertonic and draws additional fluid from
the interstitial space
Main use of the 25% concentration is as a volume expander
following a paracentesis for ascites
Dextran is a complex synthetic sugar
Dextran metabolizes slowly (remains in the vascular system for a
prolonged period)
Its action in the intravascular space is not as long as the colloids
It pulls additional fluid into the intravascular space
Hetastarch is a synthetic colloid that works similarly to dextran to
expand plasma volume

12. IV FLUID AND ELECTROLYTE REPLACEMENT
Whole blood or packed RBCs are necessary if the patient has lost
blood
Packed RBCs have the advantage of giving the patient primarily
RBCs
Packed RBCs also increase oncotic pressure and pull fluid into the
intravascular space
Whole blood (with its additional fluid volume) may cause
circulatory overload
Particularly in patients who are susceptible to complications from
excess circulating volume (e.g. heart failure)
Loop diuretics may be administered with blood to prevent
manifestations of fluid overload

13. CENTRAL VENOUS ACCESS DEVICES
•Central venous access devices (CVADs) - catheters placed
in large blood vessels (e.g. subclavian vein, jugular vein) of
people who require frequent or special access to the vascular
system
Useful with patients who have limited peripheral vascular
access or who have a projected need for long-term vascular
access (e.g. renal failure, shock, burns, heart failure)
•There are three main types of CVADs
Centrally inserted catheters
Peripherally inserted central catheters (PICCs)
Implanted ports

14. CENTRAL VENOUS ACCESS DEVICES
• Advantages of CVADs
Immediate access to the central venous system (permits frequent,
continuous, rapid or intermittent administration of IVFs and
medications)
A reduced need for multiple venipunctures and associated discomfort
Decreased risk of extravasation injury
Allow for the administration of drugs that are potential vesicants, blood
and blood products, parenteral nutrition
Provide a means to perform hemodynamic monitoring and obtain
venous blood samples
Safe for injections of radiopaque contrast media at high pressures and
controlled rates

15. CENTRAL VENOUS ACCESS DEVICES
•Major disadvantages of CVADs
Increased risk of systemic infection
Invasiveness of the procedure
Extravasation can still occur if there is displacement of or
damage to the device

16. CENTRAL VENOUS ACCESS DEVICES
• Centrally Inserted Catheters (also called central venous
catheters [CVCs]) - inserted into a vein in the neck or chest
(subclavian or jugular) or groin (femoral) with the tip resting in the
distal end of the superior vena cava
Do not use a newly place CVAD until the tip position is verified
with a chest x-ray
These catheters are single-, double-, triple-, or quad-lumen
catheters
Multi-lumen catheters are useful in the critically ill patient
All of the lumens can provide a different therapy simultaneously e.g.
incompatible drugs infuse in separate lumens without mixing while a
third lumen provides access for blood sampling

17. Central venous catheter (non-tunneled)

18. Central venous catheter (tunneled)

19. CENTRAL VENOUS ACCESS DEVICES
•Peripherally Inserted Central Catheters (PICCs) - central
venous catheters inserted into a vein in the arm (cephalic or
basilic) rather than a vein in the neck or chest
They are inserted at or just above the antecubital fossa and
advanced to a position with the tip ending in the distal one
third of the superior vena cava
PICCs are single- or multiple-lumen
They are used with patients who need vascular access for 1
week to 6 months but can be in place for longer periods

20. Peripherally inserted central catheter

21. CENTRAL VENOUS ACCESS DEVICES
•Advantages of the PICC over a central venous catheter are
Lower infection rate
Fewer insertion-related complications
Decreased cost and insertion at the bedside or outpatient area

22. CENTRAL VENOUS ACCESS DEVICES
• Implanted Infusion Ports
Implanted infusion ports consist of a central venous catheter connected
to an implanted, single or double subcutaneous injection port
The catheter tip lies in the desired vein and the other end is connected
to a port that is surgically implanted in a subcutaneous pocket on the
chest wall
The port consists of a metal sheath with a self-sealing silicone septum
Implanted ports are good for long-term therapy and have a low risk of
infection
Regular flushing is required to avoid the formation of “sludge” (clotted
blood and drug precipitate) within the port septum

23. Implanted port

24. CENTRAL VENOUS ACCESS DEVICES
•Complications
Catheter occlusion
Embolism
Catheter-related infection (local/systemic)
Pneumothorax
Catheter migration

25. CENTRAL VENOUS ACCESS DEVICES
• NURSING MANAGEMENT
• Catheter and insertion site assessment
Inspection of the site for redness, edema, warmth, drainage and
tenderness or pain
Observation of the catheter for misplacement or slippage is important
Perform a comprehensive pain assessment, particularly noting any
complaints of chest or neck discomfort, arm pain, or pain at the
insertion site
Perform hand hygiene before manipulating a catheter for any reason

26. CENTRAL VENOUS ACCESS DEVICES
• Cleansing and dressing changes
Perform dressing changes and cleanse the catheter insertion site using
strict sterile technique
Typical dressings include transparent semipermeable dressings or gauze
and tape
A gauze dressing may be preferable if the site is bleeding
Transparent dressings are preferred otherwise (allow observation of
the site without having to remove the dressing)
Transparent dressings may be left in place for up to 1week if clean,
dry and intact
Change any dressing immediately if it becomes damp, loose or visibly
soiled

27. CENTRAL VENOUS ACCESS DEVICES
• Cleansing and dressing changes
Cleanse the skin around the catheter insertion site according to institution
policy
A chlorhexidine-based preparation is the cleansing agent of choice
Its effects last longer than either povidone-iodine or isopropyl alcohol
(offers improved killing of bacteria)
Cleansing the skin with friction is critical to infection prevention when
using chlorhexidine
Allow the area to air dry completely before application of a new dressing
for chlorhexidine to be effective
Secure the lumen ports to the skin above the dressing site
Document the date and time of dressing change and initial the dressing

28. CENTRAL VENOUS ACCESS DEVICES
•Injection cap changes
Change injection caps at regular intervals according to
institution policy or if they are damaged from excessive
punctures
Use strict sterile technique
Teach the patient to turn the head to the opposite side of the
CVAD insertion site during cap change
Instruct the patient to lie flat in bed and perform the Valsalva
maneuver whenever the catheter is open to air to prevent an
air embolism (if the catheter cannot be clamped)

29. Injection cap

30. Further reading

31. CENTRAL VENOUS ACCESS DEVICES
• Maintenance of catheter patency
Flushing is one of the most effective ways to maintain lumen patency
and to prevent occlusion of the CVAD
It also keeps incompatible drugs or fluids from mixing
Use a normal saline solution in a syringe that has a barrel capacity of
10 mL or more to avoid excess pressure on the catheter
Do not apply force if resistance is felt
This could result in a ruptured catheter or create an embolism if a
thrombus is present
Prefilled syringes or single-dose vials are preferred over multiple-dose
vials (because of the risk of contamination and infection)
Clamp any unused lines after flushing

32. CENTRAL VENOUS ACCESS DEVICES
•Maintenance of catheter patency
Use the push-pause technique when flushing all catheters
Push-pause creates turbulence within the catheter lumen
(promote the removal of debris that adheres to the catheter
lumen and decreasing the chance of occlusion)
Remove the syringe before clamping the catheter to allow the
positive pressure valve to work correctly

33. CENTRAL VENOUS ACCESS DEVICES
• REMOVAL OF CVADs
Removal of CVADs is done according to institution policy and the
nurse’s scope of practice
The procedure involves removing any sutures and then gently
withdrawing the catheter
Instruct the patient to perform the Valsalva maneuver as the last 5 to
10 cm of the catheter is withdrawn
Immediately apply pressure to the site with sterile gauze to prevent air
from entering and to control bleeding
Inspect the catheter tip to determine that it is intact
Apply an antiseptic ointment and sterile dressing to the site after
bleeding has stopped