The document discusses the essential aspects of fluid, electrolytes, and acid-base balance in the human body, highlighting their importance for homeostasis and physiological functions. It covers fluid compartments, mechanisms for fluid regulation, types of disturbances in fluid volume, and electrolyte values, along with possible clinical manifestations and treatments for imbalances. Additionally, it outlines intravenous therapy as a method to maintain normal fluid and electrolyte levels, including its indications, advantages, disadvantages, and potential complications.

1. Fluid, Electrolytes, and Acid-Base Balance
By- Bandita Patra (Associate Professor)
INTRODUCTION
• Fluid electrolyte balance is a dynamic process that is crucial for life and homeostasis.
• Fluid occupies almost 60% of the weight of an adult.
• Body fluid is located in two fluid compartments: the intracellular space and the extracellular space.
• Electrolytes in body fluids are active chemicals or cations that carry positive charges and anions that
carry negative charges.
• The major cations in the body fluid are sodium, potassium, calcium, magnesium, and hydrogen ions.
• The major anions are chloride, bicarbonate, sulphate, and proteinate ions.
➢ HOMEOSTASIS- Homeostasis is the dynamic process in which the body maintains balance by constantly
adjusting to internal and external stimuli.
NEGATIVE AND POSITIVE FEEDBACK
• Feedback is the relaying of information about a given condition to the appropriate organ or system.
• Negative feedback. Negative feedback occurs when the body reverses an original stimulus for the body
to regain physiologic balance.
• Positive feedback. Positive feedback enhances or intensifies the original stimulus.
• Examples. Blood pressure control and maintenance of normal body temperature are examples of
negative feedback while blood clotting after an injury and a woman in labour are examples of positive
feedback.
Systems Involved in Feedback
• The major systems involved in feedback are the nervous and endocrine systems.
• Nervous system. The nervous system regulates homeostasis by sensing system deviations and sending
nerve impulses to appropriate organs.
• Endocrine system. The endocrine system uses the release and action of hormones to maintain
homeostasis.
BODY FLUIDS
• Fluids make up a large portion of the body, which is approximately 50%-60% of the total body
weight.
• Main compartments: - Body fluids are divided between two main compartments: the intracellular
fluid and the extracellular fluid compartments.
1. Intracellular fluid----Intracellular fluid functions as a stabilizing agent for the parts of the cell,
helps maintain cell shape, and assists with transport of nutrients across the cell membrane, in
and out of the cell.
2. Extracellular fluid----Extracellular fluid mostly appears as interstitial tissue fluid and
intravascular fluid.
FLUID REGULATION MECHANISM
1. The thirst centre: - The thirst centre in the hypothalamus stimulates or inhibits the desire for a person to
drink.

2. 2. Antidiuretic hormone. ADH regulates the amount of water the kidney tubules absorb and is released in
response to low blood volume or in response to an increase in concentration of sodium and other
solutes in the intravascular fluids.
3. The Renin Angiotensin Aldosterone system. The RAA system controls fluid volume, in which when the
blood volume decreases, blood flow to the renal juxtaglomerular apparatus is reduced, thereby
activating the RAA system.
4. Atrial natriuretic peptide. The heart also plays a role in correcting overload imbalances, by releasing ANP
from the right atrium.
NORMAL INTAKE
• Daily intake. An adult human at rest takes appropriately 2,500 ml of fluid daily.
• Levels of intake. Approximate levels of intake include fluids 1, 200 ml, foods 1, 000 ml, and
metabolic products 30 ml.
NORMAL OUT PUT
• Daily output should approximately equal in intake
• Normal output occurs as urine, breathing, perspiration, faeces, and in minimal amounts of vaginal
secretions.
DISTURBANCES IN FLUID VOLUME
1. Overhydration. Overhydration is an excess of water in the body.
2. Oedema. Oedema is the excess accumulation of fluid in interstitial tissue spaces, also called third- space
fluid.
➢Caused by a disruption of the filtration and osmotic forces of the body’s circulating fluids.
➢Treatment - Diuretics are commonly given for systemic Oedema.
3. Dehydration
➢ Dehydration is a deficiency of body water or excessive loss of water.
➢ Causes- External causes of dehydration include prolonged sun exposure and excessive exercise, as
well as diarrhoea, vomiting, and burns.
➢ Treatment of dehydration- Supplemental fluids and electrolytes are often administered.
4. Electrolytes
➢ Electrolytes is a substance that will disassociate into ions when dissolved in water.
➢ Origins- Electrolytes are found in the form of inorganic salts, acids, and bases.
➢ Active chemicals- Electrolyte concentrations are measured according to their chemical activity and
expressed as milliequivalents.
➢ Ions- Each chemical element has an electrical charge, either positive or negative.
INTRACELLULAR ELECTROLYTES
Important intracellular electrolytes are potassium, magnesium, sulphate, and phosphate, and the most
dominant cation is potassium while the most dominant anion is phosphate.
EXTRACELLULAR ELECTROLYTES
Important extracellular electrolytes include sodium, chlorine, calcium, and bicarbonate, and the most
essential cation is sodium while chlorine is the most important anion.
TRANSPORT OF FLUID AND ELECTROLYTES

3. • Total electrolyte concentration affects the body’s fluid balance.
• 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.
PERMEABLE MEMBRANE
1. Freely permeable membranes- These membranes allow almost any food or waste substance to pass
through.
2. Selectively permeable- The cell membrane is selectively permeable, meaning that each cell’s membrane
allows only certain specific substances to pass through.
PASSIVE TRANSPORT
• Passive transport mechanisms include diffusion, osmosis, and filtration.
• Diffusion- it is the process of “being widely spread”, is the random movement of molecules from an
area of higher concentration to an area of lower concentration.
• Osmosis- Osmosis is the diffusion of a pure solvent, such as water, across a semipermeable
membrane in response to a concentration gradient in situations where the molecules of a higher
concentration are non-diffusible.
• Filtration- Filtration is the transport of water and dissolved materials concentration already exists
in the cell.
ACTIVE TRANSPORT
• Active transport mechanisms require specific enzymes and an energy expenditure in the form of
adenosine triphosphate (ATP).
• Active transport processes can move solutes “uphill”, against the normal rules of concentration and
pressure.
FLUID AND ELECTROLYTE BALANCE
• Fluid and electrolyte balance is vital for proper functioning of all body systems.
• Osmolarity- This is the property of particles in a solution to dissociate into ions.
• Electroneutrality- This is the balance of positive and negative charges.
ACID BASE BALANCE
• Acid base balance is another important aspect of homeostasis.
• Acid, Bases, and Salts
• Acid- An acid is one type of compound that contains the hydrogen ion.
• Base- A base or alkali is a compound that contains the hydroxyl ion.
• Salt- A salt is a combination of a base and an acid and is created when the positive ions of a base
replace the positive hydrogen ions of an acid.
• Important salts- The body contains several important salts like sodium chloride, potassium
chloride, calcium chloride, calcium carbonate, calcium phosphate, and sodium phosphate.
POTENTIAL OF HYDROGEN
The symbol of pH refers to the potential or power of hydrogen ion concentration within the solution.

4. • Low pH- If the pH number is lower than 7, the solution is an acid.
• High pH- If the pH is greater than 7, a solution is basic or alkaline.
• Neutral pH- If the pH is 7, then the solution is neutral.
• Changes- A change in the pH of a solution by one pH unit means a tenfold change in
hydrogen concentration
BUFFER
• A buffer is a chemical system set up to resist changes, particularly in hydrogen ion levels.
• Bicarbonate buffer system- Sodium bicarbonate and carbonic acid are the body’s major chemical
buffers.
• Carbon dioxide- The major compound controlled by the lungs is CO2, and the respiratory system
can very rapidly compensate for too much acid and too little acid by increasing or decreasing the
respiratory rate, thereby altering the level of CO2.
• Bicarbonate- Bicarbonate ions are basic components in the body, and the kidneys are key in
regulating the amount of bicarbonate in the body.
• Measurement of arterial blood gas- The pH level and amounts of specific gases in the blood
indicate if there is more acid or base and their associated values.
RESPIRATORY ACIDOSIS
Respiratory acidosis occurs when breathing is inadequate and PaCO2 builds up.
• Respiratory alkalosis- Respiratory alkalosis occurs as a result of hyperventilation or excess aspirin
intake.
• Metabolic acidosis- In metabolic acidosis, metabolism is impaired, causing a decrease in bicarbonates
and a buildup of lactic acid.
• Metabolic alkalosis- Metabolic alkalosis occurs when bicarbonate ion concentration increases,
causing an elevation in blood pH
CLASSIFICATION-
There are different fluid volume disturbances that may affect an individual.
• Fluid volume deficit or hypovolemia occurs when loss of ECF volume exceeds the intake of fluid.
• Fluid volume excess or hypervolemia refers to an isotonic volume expansion of the ECF caused by the
abnormal retention of water and sodium in approximately the same proportions in which they
normally exist in the ECF.
• Disturbances in electrolytes balances are common in clinical practice and must be corrected.
1. Hyponatremia refers to a serum sodium level that is less than 135 mEq/L
2. Hypernatremia is a serum sodium level higher than 145 mEq/L.
3. Hypokalaemia usually indicates a deficit in total potassium stores.
4. Hyperkalaemia refers to a potassium level greater than 5.0 mEq/L.
5. Hypocalcaemia are serum levels below 8.6 mg/dl
6. Hypercalcemia is calcium level greater than 10.2 mg/dl.
7. Hypomagnesemia refers to a below- normal serum magnesium concentration.
8. Hypermagnesemia are serum levels over 2.3 mg/dl.
9. Hypophosphatemia is indicated by a value below 2.5 mg/dl.
10. Hyperphosphatemia is a serum phosphorus level that exceeds 4.5 mg/dl in adults.

5. Pathophysiology
Nurses needs an understanding of the pathophysiology of fluid and electrolyte balance to anticipate,
identify, and respond to possible imbalances.
• Concentrations- Electrolyte concentrations vary from those in the ICF to those in the ECF.
• Sodium- Sodium ions outnumber any other cations in the ECF; therefore, it is essential in the fluid
regulation of the body.
• Potassium- The ECF has a low concentration of potassium and can tolerate only small changes in
its concentrations.
• Maintenance- The body expends a great deal of energy in maintaining the sodium and potassium
concentrations through cell membrane pumps that exchange sodium and potassium ions.
• Osmosis- When two different solutions are separated by a membrane that is impermeable to the
dissolved substances, fluid shifts from the region of low solute concentration to the high solute
concentration until the solutions are of equal concentrations.
• Diffusion- Diffusion is the natural tendency of a substance to move in an area of higher
concentration to an area of lower concentration.
Causes of fluid and electrolyte imbalances are discussed below in general.
Fluid retention-
• Retention of sodium is associated with fluid retention.
• Loss of sodium- Excessive loss of sodium is associated with decreased volume of body fluid.
• Trauma- Trauma causes release of intracellular potassium which is extremely dangerous.
• Loss of body fluids- FVD results from loss of body fluids and occurs more rapidly when coupled with
decreased fluid intake.
Fluid overload-
• Fluid volume excess may be related to a simple fluid overload or diminished function of the homeostatic
mechanisms responsible for regulating fluid balance.
• Low or high electrolyte intake. Diets low or excessive in electrolytes could also cause electrolyte
imbalances.
• Medications. There are certain medications that could lead to electrolyte imbalances when taken against
the physician’s orders.
CLINICAL MENIFESTATION
Signs and symptoms that occur in fluid and electrolyte imbalances: -
1. Fluid volume deficit-
Clinical signs and symptoms include acute weight loss, decreased skin turgor, oliguria, concentrated
urine, orthostatic hypotension, a weak, rapid heart rate, flattened neck veins, increased temperature,
thirst, decreased or delayed capillary refill, cool, clammy skin, muscle weakness, and cramps.
2. Fluid volume excess-
Clinical manifestations for FVE include oedema, distended neck veins, and crackles.
3. Hyponatremia-
Signs and symptoms include anorexia, nausea and vomiting, headache, lethargy, dizziness, confusion,
muscle cramps and weakness, muscular twitching, seizures, dry skin, and oedema.

6. signs and symptoms are thirst, elevated body temperature, hallucinations, lethargy, restlessness,
pulmonary oedema, twitching, increased BP and pulse.
1. Hypokalaemia: - Clinical manifestations are fatigue, anorexia, muscle weakness, polyuria,
decreased bowel motility, paraesthesia, ileus, abdominal distention, and hypoactive reflexes
2. Hyperkalaemia: - Signs and symptoms include muscle weakness, tachycardia, paraesthesia,
dysrhythmias, intestinal colic, cramps, abdominal distention, and anxiety.
3. Hypocalcaemia: - signs and symptoms are numbness, tingling of fingers, toes, and
circumoral region, positive Trousseau’s sign and Chvostek’s sign, seizures, hyperactive deep
tendon reflexes, irritability, and bronchospasm.
4. Hypercalcemia. The signs and symptoms include muscle weakness, constipation, anorexia,
nausea and vomiting, dehydration, hypoactive deep tendon reflexes lethargy, calcium
stones, flank pain, pathologic fractures, and deep bone pain.
5. Hypomagnesemia: -Clinical manifestations include neuromuscular irritability, positive
Trousseau’s and Chvostek’s sign, insomnia, mood changes, anorexia, vomiting, and
increased deep tendon reflexes.
6. Hypermagnesemia: - signs and symptoms are flushing, hypotension, muscle weakness,
drowsiness, hypoactive reflexes, depressed respirations, and diaphoresis.
7. Hypophosphatemia: - Signs and symptoms include paraesthesia, muscle weakness, bone
pain and tenderness, chest pain, confusion, seizures, tissue hypoxia, and nystagmus.
8. Hyperphosphatemia: - Clinical manifestations are tetany, tachycardia, anorexia, nausea and
vomiting, muscle weakness, and hyperactive reflexes.
COMPLICATION
Fluid and electrolyte imbalances could result in complications if not treated promptly.
• Dehydration- Fluid volume deficit could result in dehydration of the body tissues.
• Cardiac overload- Fluid volume excess could result in cardiac overload if left untreated.
• SIADH- Water is retained abnormally in SIADH (Syndrome of inappropriate antidiuretic hormone).
• Cardiac arrest- Too much potassium administered could lead to cardiac arrest.
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7. INTRAVENOUS THERAPY
INTRAVENOUS (IV) THERAPY:
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. IV
fluid therapy 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.
Definition: Infusion of a fluid into a vein to prevent or treat fluid &/or electrolyte
imbalance(s) and to deliver medications/ blood products.
Purposes of Infusion Therapy:
• Provide fluids when PO intake not possible
• replace fluids/electrolytes
• Maintain normal electrolyte balances
• Provide glucose as energy source
• Provide access for administration of meds
• Administer blood products
• Emergency access
• Maintain urine output
Indications for IV Therapy
• Fluid Volume maintenance
• Fluid Volume replacement
• Medication Administration
• Blood and Blood Product Donation and administration
• Nutritional support.
Principles of iv therapy
Advantage: -
• Accurate, controlled & predictable way of administration.
• Immediate response.
• Prompt correction of serous fluid & electrolyte disturbances.
Disadvantages: -
• More expensive, need strict asepsis.
• Improper selection of type of fluid used can lead to serious problems.
• Improper volume & rate of infusion can be life threatening.

8. • Improper technique of administration can lead to complication.
Contraindication: -
Preferable to avoid in patients with congestive heart failure & volume overdose.
Complication: -
1) Local - Hematoma, infiltration, infusion phlebitis.
2) Systemic - Circulation overload, Rigors, air embolism, septicaemia.
3) Others - Fluid contamination, mixing of incompatible drugs
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COMMON VENIPUNCTURE SITES
VENIPUNCTURE: it is a technique of accessing a vein via insertion of a needle or
catheter with sterile procedure because skin integrity is broken.
• Cephalic Vein – thumb side
• Basilic Vein - little finger side
• Median Cubital vein – connects
cephalic and basilic
• Medial vein of forearm – centre of the
forearm
• Radial vein – wrist area, thumb side
• Superficial dorsal veins
• Dorsal venous arch
TYPE OF IV FLUIDS
common way to categorize IV fluids is based on their tonicity:

9. 1. Isotonic- Isotonic IV solutions that have the same concentration of solutes as
blood plasma.
2. Hypotonic- Hypotonic solutions have lesser concentration of solutes than plasma.
3. Hypertonic- Hypertonic solutions have greater concentration of solutes than plasma.
IV solutions can also be classified based on 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. 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.
CRYSTALLOID IV SOLUTIONS CONTAIN SMALL MOLECULES THAT FLOW EASILY
ACROSS SEMIPERMEABLE MEMBRANES.
They are categorized according to their relative tonicity in relation to plasma. There are
three types: isotonic, hypotonic, and hypertonic.
1. Isotonic IV Fluids
Most IV fluids are isotonic, meaning, they have the same concentration of
solutes as blood plasma. When infused, isotonic solutions expand both
the intracellular fluid and extracellular fluid spaces, equally. Such fluids do
not alter the osmolality of the vascular compartment. Technically,
electrolyte solutions are considered isotonic if the total electrolyte content
is approximately 310 mEq/L. Isotonic IV fluids have a total osmolality close
to that of the ECF and do not cause red blood cells to shrink or swell.

10. 1.1 saline (0.9% NaCl)
Composition: -
One litre fluid contains - Na+ = 154 mEq Cl- = 154 mEq
Distributed chiefly in extracellular fluid, so it will increase intravascular volume
substantially
Indication: -
1) Resuscitation fluid in diarrhoea, vomiting, excessive diuresis.
2) Treatment of Hypovolemic shock.
3) Initial fluid therapy in Diabetic ketoacidosis.
4) Fluid challenge in pre-renal ARF.
5) AS vehicle for certain drugs and can be safely given with blood.
Contraindication: -
1) Avoid in hypertensive or pre-eclamptic patients.
2) CHF ,Renal diseases and cirrhosis.

12. 1.2. 5% dextrose with 0.9%NaCl)
Composition: - One litre fluid contains - Glucose = 50 gm Na+ = 154 mEq Cl- = 154 mEq
Distributed chiefly in extracellular fluid,
Indication: -
• Correction of salt depletion and hypovolemia with supply of energy.
• Fluid compatible with blood transfusion.
• Correction of vomiting or nasogastric aspiration infused alkalosis.
Contraindication: -
1) Anasarca – cautious use in anasarca of cardiac, hepatic and renal disease
2) Hypovolemic shock- Rapid infusion can cause Hyperglycaemia and osmotic diuresis even in presence of
fluid deficit.
RINGER’S LACTATE
Composition: -
• 1 Litre of fluid contains - Sodium = 130 mEq Calcium = 3 mEq Potassium = 4 mEq Bicarbonate =
28 mEq Chloride = 109 mEq
• Ringer lactate is the most physiological fluid as its electrolyte content is nearly similar to that of
plasma. Because of high Sodium conc.
• It rapidly expands intravascular volume and so very effective in treatment of severe hypovolemia.
Indication: -
• Correction of severe Hypovolemia rapidly with large fluid volume.
• For replacing fluid in post operative patients, burns, fractures etc.
• Treatment of Diarrhoea induced hypovolemia with hypokalaemia metabolic acidosis.
• In Diabetic keto acidosis, RL provides glucose free water.
• For maintaining normal ECF fluid and electrolyte balance during and after surgery.
Contradiction: -
a. It can lead to lactic acidosis in patients with Liver disease, Hypoxia and shock
b. Severe CHF.
c. Addison’s disease
d. In vomiting or continuous Nasogastric aspiration
e. Along with Blood transfusion
f. The calcium in RL binds with certain drugs like amphotericin, thiopental and reduces their
bioavailability and efficiency.
ISOLYTE-M
(Maintenance sol. With 5% dextrose)
Composition: -
• One litre fluid contains - Glucose 0 gm Phosphate = 15 mEq Na+ = 40 mEq Acetate = 20 mEq Cl-
= 38 mEq K+ = 35 mEq
• Isolyte – M is the richest source of potassium so very useful in treatment of hypokalaemia
• Proportions of electrolytes in Isolyte-M is almost similar to maintenance requirement of the body

13. Indication: -
• For Parenteral fluid therapy, it’s the ideal maintenance fluid.
• To correct hypokalaemia secondary to diarrhoea, bilious vomiting etc.
Contraindication: -
• Acute and chronic renal failure.
• Hyponatremia.
• Adrenocortical insufficiency.
• In patients with burns.
ISOLYTE- E
(Extracellular replacement solution)
Composition: -
• One litre fluid contains - Glucose = 50 gm Acetate = 47 mEq Na+ = 140 mEq Ca ++ = 5 mEq Cl- =
103 mEq Mg++ = 3 mEq K+ = 10 mEq Citrate = 8 mEq
• Isolyte – E has electrolyte similar to ECF except double the conc. of potassium and acetate.
• Only I.V. fluid available that can correct magnesium deficiency.
Indication: -
• Maintenance of ECF volume preoperatively.
• Diarrhoea.
• Metabolic acidosis.
Contraindication:
• Vomiting
• Continuous Nasogastric aspiration.
• In metabolic alkalosis due to drugs and bicarbonate
SPECIAL FLUIDS
1. SODIUM BIOCARBONATE (NaHCO3)
Composition: -
Commonly used preparation is 7.5%, 25 ml ampoule One ampoule contains 22.5 mEq Sodium and 22.5
mEq
Bicarbonate Amount to be infused Approximately 50% of the calculated deficit is corrected in 4 Hrs and
rest gradually over 24 hrs Amount of NaHCO3 required (in mEq/L) = 0.5 X weight in Kg X (Desired HCO3 -
actual HCO3)
Special precautions
• Sodium bicarbonate should not be given as bolus except in emergency.
• Avoid overdose and alkalosis by giving repeated small doses and monitoring pH
• Never treat Acidosis without treating the aetiology.
• In presence of renal failure, treatment with sod. Bicarbonate may cause tetany and pulmonary
oedema.
• Never correct acidosis without correcting the associated hypokalaemia. NaHCO3 will shift
potassium from ECF to ICF, this will aggravate hypokalaemia

14. • Never mix inj. Calcium with inj. NaHCO3 in same syringe as it may precipitate calcium
carbonate.
• Avoid mixing of inj. NaHCO3 with inotropes.
Indication: -
• Metabolic acidosis
• Cardiopulmonary resuscitation and shock.
• Treatment of Hyperkalaemia.
• Alkaline forced diuresis in acute poisoning of barbiturates and salicylates.
Complication:
Hypokalaemia, volume overload, hypocalcaemia
Contraindication: -
1) Respiratory and metabolic alkalosis.
2) Hypokalaemia.
3) Cautious use in CHF, CRF, cirrhosis.
INJECTABLE POTASSIUM CHLORIDE
Composition: -
preparation is 15% KCl 10ml ampoule. 1 ml = 150 mg KCl = 2mEq Potassium.
So 1 ampoule = 10 ml = 20 mEq Potassium.
Indication: -
• Added in potassium free I.V. fluids for prevention of Hypokalaemia
• For treating Hypokalaemia.
• Added to potassium free peritoneal dialysis fluid for maintaining proper K+ levels
Basic rules for using Inj. KCl: -
• Never give direct I.V. KCl injection.
• Always use injection potassium chloride diluted in infusion.
• Never add more than 40 mEq / litre.
• Never infuse more than 10 mEq / hr.
• Never add KCl in Isolyte – M.
• Monitor serum K+ levels closely.
Contraindication: -
1) Cautious use in renal failure as hyperkalaemia is a potential risk.
2) Never use injection KCl without knowing potassium status.
COLLOIDS
ALBUMIN: -
Composition: -
• Albumin is a physiological plasma protein.
• Heat treated preparation of human serum albumin is commercially available in a 5% solution (50 gm/dl)
and a 25% solution (250 gm/dl).
• As Sodium load is small, 25% albumin is also called salt poor albumin

15. Indication: -
1) For Plasma volume expansion in cases of acute hypovolemic shock, burns.
2) Correction of hypoproteinaemia as in liver disease, nephrotic syndrome etc.
3) As an exchange fluid to replace removed plasma in therapeutic plasmapheresis.
Adverse effect: -
▪ Nausea and vomiting.
▪ Febrile reaction.
▪ Allergic reaction and anaphylactic shock.
Precautions and contraindications :-
1) Fast infusion will rapidly increase circulatory volume with resultant overload and pulmonary oedema.
2) Infusion of albumin solution is contraindicated in patients with severe anaemia or cardiac failure .
3) Should be given with caution to patients with low cardiac reserves.
4) Albumin solution should not be used for parenteral nutrition.
DEXTRAN
Composition: -
• Dextran and glucose polymers produced by bacteria incubated in sucrose media.
• Available in two forms: DEXTRAN 70 -- mol. wt. 70,000 DEXTRAN 40 – mol. wt. 40,000 Both forms
effectively expand Intra vascular volume but cannot be a substitute for whole blood due to lack of
oxygen carrying capacity and no clotting factors.
Indication: -
• For short term rapid expansion of plasma volume for correction of hypovolemia.
• Prophylaxis of Deep vein thrombosis and postoperative thromboembolism.
• To improve blood flow and microcirculation in threatened vascular gangrene.
Adverse effect: -
• Acute renal failure.
• Hypersensitivity reaction.
• It may interfere with blood grouping and cross matching.
Contraindication: -
• Severe oligo-anuria and renal failure.
• Known hypersensitivity to dextran.
• Severe CHF or circulatory overload.
• Bleeding disorders.
• Severe Dehydration.
Preauction: -
1) The haematocrit should not be allowed to fall below 30.
2) Correct dehydration during dextran infusion to maintain adequate urine flow.
3) Anticoagulant effect of heparin enhanced by dextran.
4) Along with dextran infusion patient may require blood coagulation factor or electrolyte.

16. --------------------------------------------------------------------------------------------------------------------
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INTRAVENOUS FLUID CALCULATION
Types of IV Fluids
D5W = D5%W
D5S = D5% 0.9NS
D5½NS = D5% 0.45NS
NS = 0.9% NS
½NS = 0.45% NS
IV Drip Factors
Micro drip = 60 gtt/mL
Macro drip—need to check package
To calculate IV drip rates, this information must be known.
Electric Infusion Pumps
Volume for infusion
Rate for infusion
Turn pump on
IV Piggybacks on Electronic Infusion Pumps
• Secondary volume
• Secondary rate
• Turn pump on
Number of millilitres to infuse × Drop factor =Drops per minute or gtt/minute
Number of minutes to infuse
When the order reads “hour,” convert to minutes by multiplying by 60 (60 minutes = 1 hour).
Calculating IV Drips for Infusion Pump
Total number of millilitres ordered =mL/hour
Number of hours to run
Question Order: 1000 mL D5W at 120 mL/hour Available macro drip 15 gtt/mL What is the drip factor in
drops per minute?
A. 30 gtt/minute
B. 31 gtt/minute
C. 32 gtt/minute
D. 33 gtt/minute
Answer 30 gtt/minute120 mL×15 gtt/mL =30 gtt/minute
60 minutes

17. Determining Hours an IV Will Run
Number of millilitres ordered =
Number of millilitres per hour
Question -2
How many hours will 500 mL of D5½NS run at 75 mL/hour? Round to the nearest whole number.
a. 4 hours
b. 5 hours
c. 6 hours
d. 7 hours
Answer-
500 mL =6.7 or 7 hours
75 mL/hour
Number of millilitres ordered =Number of hours to run500 mL 75 mL/hour =6.7 or 7 hours
Number of millilitres per hour
Choosing the Infusion Set
• Micro drip IV administered over a long period small amount of fluid to be infused Macro drops per
minute are too few.
• Macro drip Order specifies a large amount of fluid over a short time. Micro drips per minute are
too many, and counting the drip rate becomes too difficult.
COMPLICATION OF IV FLUID THERAPY
• The most common complications of this therapy are
• hyponatraemia (if excessive IV water is administered)
• volume overload (if excessive sodium and water are administered)
• and volume depletion and/or acute kidney injury (if inadequate sodium and water are
administered).
Classified according to their location
• Local complication: at or near the insertions site or as a result of mechanical
failure hematoma, thrombosis, phlebitis, post infusion phlebitis, thrombophlebitis, infiltration,
extravasation, local infection, and venous spasm.
1. Hematoma and ecchymosis-

18. ▪ Demote formations resulting from the infiltration of blood into the
tissues at the venipuncture site Related to venipuncture technique .
▪ Use of large bore cannula: Trauma to the vein during insertion
▪ Patients receiving anticoagulant therapy and long term steroids
2. Thrombosis-
▪ Catheter-related obstructions can be mechanical or non-thrombotic
▪ Trauma to the endothelial cells of the venous wall causes red blood
cells to adhere to the vein wall, forms a clot or Thrombosis
▪ Drip rate slows, line does not flush easily, resistance is felt
▪ Never forcible flush a catheter
3. Phlebitis-
Inflammation of the vein in which the endothelial cells of the venous wall
become irritated and cells roughen, allowing platelets to adhere and predispose
the vein to inflammation-induced phlebitis.
• Tender to touch and can be very painful
4. Thrombophlebitis: -
Thrombophlebitis denotes a twofold injury: thrombosis and inflammation Related to:
• Use of veins in the lower extremity
• Use of hypertonic or highly acidic infusion solutions
• Causes similar to those leading to phlebitis
5. Infiltration: -
The inadvertent administration of a non-vesicant solution into surrounding tissue • Dislodgment of the
catheter from the vein
• Second to phlebitis as a cause of IV therapy morbidity
6. Venous Spasm: -
A sudden involuntary contraction of a vein or an artery resulting in temporary cessation of blood flow through a
vessel.
Systemic complications: occur within the vascular system, remote from the IV site. Can be serious and
life threatening.

19. MEASURING FLUID INTAKE AND OUT PUT
Intake and output 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 (millilitre).
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.
Remember! Intake Oral fluids Ice chips Foods that are tend to become liquid at room
temperature Tube feedings Parenteral fluids Intravenous medications Catheter or tube
irrigants.
Output- Remember! Urine Vomitus and liquid faeces Tube drainage Wound drainage
and draining fistulas
Measurement-
• 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)
Significance of Measuring Intake and Output Inform Required Explain Emphasize
Clinical Do's and Don’ts
a. Do 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.

20. • 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.
b. DO 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.
c. DO 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.
d. DO 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.
e. DON’TS: -
• 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 colour, colour changes, and
Odor too.
• Don't use the same graduated container for more than one patient.
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21. ADMINISTERING BLOOD AND BLOOD COMPONENT
A blood administration (transfusion) is a routine medical procedure in which donated blood is provided
to you through a narrow tube placed within a vein in your arm. This potentially life-saving procedure can
help replace blood lost due to surgery or injury.
List out the blood components
1. Packed red blood cells
• Red blood cells are a blood product used to replace erythrocytes.
• Each unit increases the haemoglobin level by 1 g/dL and haematocrit by 2% to 3% ; the change in
laboratory values takes 4 to 6 hours after completion of the blood transfusion.
• Evaluation of an effective response is based on the resolution of the symptoms of anaemia and an
increase in the erythrocytes count.
2. Platelets
• Platelets are used to treat thrombocytopenia and platelet dysfunctions.
• Crossmatching is not required but usually is done (platelet concentrates contain few blood cells).
• The volume in a unit of platelets may vary; always check the bag for the volume of the blood component
(in millilitres).
• Platelets are administered immediately on receipt from the blood bank and are given rapidly, usually over
15 to 30 minutes.
• Evaluation of an effective response is based on improvement in the platelet count and platelet counts
normally are elevated 1 hour and 18 to 24 hours after the transfusion.
3 Fresh frozen plasma
• Fresh frozen plasma may be used to provide clotting factors or volume expansion; it contains no
platelets.
• Fresh frozen plasma is infused within 2 hours of thawing, while clotting factors are still viable, and is
infused as rapidly as possible.
• Rh compatibility and ABO compatibility are required for the transfusion of the plasma products.
• Evaluation of an effective response is assessed by monitoring coagulation studies, particularly the
prothrombin time and the partial thromboplastin time and resolution of hypovolemia.
4. Albumin
• Albumin is prepared from the plasma and can be stored for 5 years.
• It is used to treat hypovolemic shock or hypoalbuminemia.
• Albumin, 25g/100 mL, is equal to 500 mL of plasma.
5. Cryoprecipitates
• Prepared from fresh frozen plasma and can be stored for 1 year; once thawed, the product must be used.
• Used to replace clotting factors, especially factor Vlll and fibrinogen.
Types of blood donations
A. Autologous
• A donation of the client’s own blood before a scheduled procedure is autologous; it reduces the risk of
disease transmission and potential transfusion complications.
• Autologous donation is not an option for a client with leukaemia or bacteraemia.
• A donation can be made every 3 days as long as the haemoglobin remains within a safe range.
• Donation should begin within 5 weeks of the transfusion date and end at least 3 days before the date of
donation.
B. Blood salvage
• Blood salvage is an autologous donation that involves suctioning blood from body cavities, joint spaces,
or other closed body sites.

22. • Blood may need to be "washed" a special process that removes tissue debris before reinfusion.
C. Designated donor
• Designated donation occurs when recipients select their own compatible donors.
• Donation does not reduce the risk of contracting infections transmitted by the blood; however, recipients
feel more comfortable identifying their donors.
Compatibility chart for Red blood cell transfusions
........Recipient..............
Donor: A B AB O
A x - x -
B - x x -
AB - x -
O x x x x
Compatibility
• Client (the recipient) blood sample are drawn and labelled at the client's bedside at the time the blood
sample is drawn; the client is asked to state his or her name, which is compared with the name on the
client's identification band or bracelet.
• The recipient ABO type and Rh type are identified.
• An antibody screen is done to determine the presence of antibodies other than anti-A and anti-B.
• Crossmatching is done, in which donor red blood cells are combined with the recipient's serum and
coomb's serum; the cross math is compatible if no red blood cell agglutination occurs.
• The universal red blood cell donors are O negative; the universal recipient is AB positive.
Transfusion reaction
Description
• A transfusion reaction is an adverse reaction that occurs as a result of receiving a blood transfusion.
• Type of transfusion reaction includes haemolytic, allergic, febrile or bacterial reactions, circulatory
overload, or transfusion-associated graft-versus-host disease.
Signs of an immediate transfusion reaction
• Chills and diaphoresis
• Muscle aches, back pain, or chest pain
• Rashes, hives, itching, and swelling
• Rapid, thready pulse
• Dyspnoea, cough or wheezing
• Pallor and cyanosis
• Apprehension
• Tingling and numbness
• Headache
• Nausea, vomiting, abdominal cramping, and diarrhoea
Signs of transfusion reaction in an unconscious client
• Weak pulse
• Fever
• Tachycardia or bradycardia
• Hypotension
• Visible haemoglobinuria
• Oliguria or anuria

23. Delayed transfusion reactions
• Reaction can occur days to years after a transfusion
• Signs include fever, mild jaundice, and a decreased haematocrit level.
Intervention -+
• Stop the transfusion
• Keep the intravenous line open with 0.9% normal saline.
• Notify the physician and blood bank.
• Remain with the client, observing signs and symptoms and monitoring vital signs as often as every 5
minutes.
• Prepare to administer emergency medication such as antihistamines, vasopressors, fluids and
corticosteroids as prescribed.
• Obtain a urine specimen for laboratory studies.
RESTRICTION FLUID RESTRICTION
Fluid Restriction means that you can only have a certain amount of liquid each day.
If a person needs to change or restrict the liquids that they are taking in, their doctor or healthcare provider will
let them know. Their doctor or healthcare provider will also tell them the reason for the Fluid Restriction and how
much liquid they can drink per day. Since water is essential for all body functions, there is a delicate balance to
maintain enough hydration. It is important to work with your healthcare provider and always feel free to share
your questions or concerns about changes to your diet and your general care.
Although there are many different circumstances where a person may be prescribed to follow a Fluid
Restriction diet, some of the more common medical conditions and associated symptoms requiring fluid
restriction are listed below:
• Heart problems, including Congestive Heart Failure (CHF)
• Kidney problems, including End Stage Renal Disease (ESRD) and people undergoing dialysis
• Endocrine System and Adrenal gland disorders, including Adrenal Insufficiency
• Conditions that cause the release of stress hormones
• Treatment with medications called corticosteroids
• Low levels of Sodium in your body also known as Hyponatremia
Signs and Symptoms of Fluid Overload (too much fluid in your body)
Although your healthcare provider will often examine you and test your blood, it is also very important to take
charge of your health and monitor yourself. Watch out for:
• Swelling of the hands, ankles, and/or feet
• Increased size of the veins in your neck
• Weight gain
• Rapid heartbeat
• Increased blood pressure
• Increased urination
• Changes in mental status
Treatment Considerations
In addition to following a low-sodium diet and taking diuretics (“water pills”) as prescribed by your healthcare
provider, a Fluid Restriction can help to achieve your health goals. Depending on the fluid limit outlined for your
condition and prescribed by your healthcare provider the following are strategies to help manage your daily fluid
intake:

24. 1. Plan out the amount of liquid you will have during the day: how much will you drink to take your
medications? How much will you drink with your meals? In order to decide what works best for you, it is
helpful to sit down with a nutritionist or nurse and talk with friends and family who may be able to
support you. By identifying preferred drinks and your drinking pattern, you will more easily be able to
decide how to adjust to your Fluid Restriction.
2. Use small cups: using a small cup can give the perception of a full glass.
3. Use a designated container: some people find it helpful to measure out their daily fluid allowance in
one large container and drink only from there throughout the day.
4. Maintain good oral care: by brushing your teeth after meals, rinsing with alcohol free mouthwash,
chewing sugarless gum or sucking on hard candy you may be able to decrease dry mouth and urges to
drink.
5. Avoid foods with high levels of sodium (salt): these types of foods will increase your thirst;
6. Weigh yourself daily: it is important to use the same scale around the same time each day to get the
most accurate information and report any weight gain of 2 pounds or more in one day to your physician;
7. Record your fluid intake: recording your fluid intake will help make sure that you are not taking in more
fluids than expected. It is a good idea to write this information on a tracking log/calendar (a sample is
attached).
• You will need to learn the number of cc’s (cubic centimetres) or ml’s (millilitres) in common
servings. Some sample measurements are included below.
• Soups, food prepared with water, and semi-solids such as popsicles and Jello should count
toward your total daily fluid intake.
Helpful Tips to Remember:
• Food that melts at room temperature is considered a liquid.
• Include liquid amounts when taking your medications.
• Maintain a daily log and track all fluid intake.
• Satisfy thirst by sucking on an ice cube, hard candy, chewing gum, or rinsing mouth with water-but do
not swallow.
Fluid measurements
1 ounce = 30 cc
8 ounces = 240 cc
1 cup = 8 ounces = 240 cc
Sample measurements
Coffee cup = 200 cc
Clear glass = 240 cc
Milk carton = 240 cc
Small milk carton = 120 cc
Juice, Jell-o or ice cream cup = 120 cc
Soup bowl = 160 cc
Popsicle half = 40 cc
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25. ENHANCING FLUID INTAKE
• Getting enough fluid every day is important for your health.
• Dehydration can cause headaches, lethargy, muscle weakness and a host of other problems.
• So, what is adequate hydration, and how do we meet these needs through drinking and eating?
• Here are some tips.
1. Drink a water-based beverage (water, juice or milk) with every meal and snack — between 8 and
16 oz. You should drink a minimum of 8–10 cups per day, but aim for 10–12 cups if you are more active.
(1 cup = 8 oz.)
2. Consume fluids before you are thirsty. By the time you are thirsty, your body is already dehydrated!
Use the colour of your urine as an indicator to know if you are drinking enough. Urine should be a pale-
yellow colour. If you notice a darker yellow, you may need to increase your fluid intake.
3. If you drink caffeinated beverages (coffee, tea and sodas), alternate decaffeinated beverage intake
throughout the day. Caffeinated beverages and alcohol are diuretics. Diuretics increase the excretion of
water from the body rather than hydrating.
4. Try calorie-free, fruit-flavoured waters to add some variety. Some versions are flavoured no-calorie
waters, some are flavoured with low-calorie sweeteners and others contain enhancements like vitamins
(speak with a Registered Dietitian or physician prior to consuming these).
5. Dilute juices. For some people, fruit and vegetable juices taste too thick or sweet. Some just people just
don’t want the extra calories. Try diluting them with water or, for a fizzy kick, use club soda.
6. Eat your water. Most of your fluid needs are met through the water and beverages you drink. However,
you can get some fluids through the foods that you eat as well. For example, broth soups and foods with
high water content – such as celery, tomatoes, or melons – can contribute to fluid intake.
7. Carry a water bottle with you. This is a great way to maintain your hydration level when doing outdoor
activities or running errands, especially in warmer months. Aim for reusable bottles, and make sure they
are BPA-free.
8. Order water when eating out. This will keep you hydrated, save money and reduce calories all at the
same time.
9. Add citrus. Adding a slice of lime or lemon to your water may improve the taste and make you want to
drink more water than you usually do.
10. Keep a “water intake” journal. Seeing your track record can help motivate you to maintain your fluid
requirements. Try one of the many apps that track fluids, calories and nutrients.
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