Fluids and Electrolytes

Fluid,
Electrolyte,
and
AcidBase
Balance
LEARNING OUTCOMES
After completing this chapter, you will be able to:
1. Discuss the function, distribution, movement, and regu-
lation of fluids and electrolytes in the body.
2. Describe the regulation of acidbase balance in the
body, including the roles of the lungs, the kidneys and
buffers.
3. Identify factors affecting normal body fluid, electrolyte,
and acidbase balance.
4. Discuss the risk factors for and the causes and effects of
fluid, electrolyte, and acidbase imbalances.
5. Collect assessment data related to the clients fluid,
electrolyte, and acidbase balances.
6. Identify examples of nursing diagnoses, outcomes, and
interventions for clients with altered fluid, electrolyte, or
acidbase balance.
7. Teach clients measures to maintain fluid and electrolyte
balance.
8. Implement measures to correct imbalances of fluids
and electrolytes or acids and bases such as enteral or
parenteral replacements and blood transfusions.
9. Evaluate the effect of nursing and collaborative inter-
ventions on the clients fluid, electrolyte, or acidbase
balance.
CHAPTER
52
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hematocrit, 1449
hemolytic transfusion reaction,
1473
homeostasis, 1424
hydrostatic pressure, 1427
hypercalcemia, 1441
hyperchloremia, 1442
hyperkalemia, 1438
hypermagnesemia, 1442
hypernatremia, 1438
hyperphosphatemia, 1442
hypertonic, 1427
hypervolemia, 1435
hypocalcemia, 1441
hypochloremia, 1442
hypokalemia, 1438
hypomagnesemia, 1442
hyponatremia, 1438
hypophosphatemia, 1442
hypotonic, 1427
hypovolemia, 1435
insensible fluid loss, 1428
interstitial fluid, 1425
intracellular fluid (ICF), 1424
intravascular fluid, 1424
ions, 1425
isotonic, 1427
metabolic acidosis, 1442
metabolic alkalosis, 1442
milliequivalent, 1425
obligatory losses, 1429
oncotic pressure, 1427
osmolality, 1427
osmosis, 1426
osmotic pressure, 1427
overhydration, 1437
peripherally inserted central
venous catheter (PICC), 1456
pH, 1432
pitting edema, 1436
plasma, 1424
renin-angiotensin-aldosterone
system, 1429
respiratory acidosis, 1442
respiratory alkalosis, 1442
selectively permeable, 1426
solutes, 1426
solvent, 1426
specific gravity, 1449
third space syndrome, 1435
transcellular fluid, 1425
volume expanders, 1456
acid, 1432
acidosis, 1433
active transport, 1428
agglutinins, 1472
agglutinogens, 1472
alkalosis, 1433
anions, 1425
antibodies, 1472
antigens, 1472
arterial blood gases (ABGs), 1449
bases, 1432
buffers, 1433
cations, 1425
central venous catheters, 1456
colloid osmotic pressure, 1427
colloids, 1426
compensation, 1442
crystalloids, 1426
dehydration, 1437
diffusion, 1427
drip factor, 1465
electrolytes, 1425
extracellular fluid (ECF), 1424
filtration, 1427
filtration pressure, 1427
fluid volume deficit (FVD), 1435
fluid volume excess (FVE), 1435
KEY TERMS
In good health, a delicate balance of fluids, electrolytes, and
acids and bases is maintained in the body. This balance, or phys-
iologic homeostasis, depends on multiple physiologic
processes that regulate fluid intake and output and the move-
ment of water and the substances dissolved in it between the
body compartments.
Almost every illness has the potential to threaten this bal-
ance. Even in daily living, excessive temperatures or vigorous
activity can disturb the balance if adequate water and salt intake
is not maintained. Therapeutic measures, such as the use of di-
uretics or nasogastric suction, can also disturb the bodys home-
ostasis unless water and electrolytes are replaced.
BODY FLUIDS AND ELECTROLYTES
The proportion of the human body composed of fluid is surpris-
ingly large. Approximately 60% of the average healthy adults
weight is water, the primary body fluid. In good health this vol-
ume remains relatively constant and the persons weight varies
by less than 0.2 kg (0.5 lb) in 24 hours, regardless of the amount
of fluid ingested.
Water is vital to health and normal cellular function, serving as
Amedium for metabolic reactions within cells.
A transporter for nutrients, waste products, and other
substances.
Alubricant.
An insulator and shock absorber.
One means of regulating and maintaining body temperature.
Age, sex, and body fat affect total body water. Infants have
the highest proportion of water, accounting for 70% to 80% of
their body weight. The proportion of body water decreases with
aging. In people older than 60 years of age, it represents only
about 50% of the total body weight. Women also have a lower
percentage of body water than men. Women and the elderly
have reduced body water due to decreased muscle mass and a
greater percentage of fat tissue. Fat tissue is essentially free of
water, whereas lean tissue contains a significant amount of wa-
ter. Water makes up a greater percentage of a lean persons body
weight than an obese persons.
Distribution of Body Fluids
The bodys fluid is divided into two major compartments, intra-
cellular and extracellular. Intracellular fluid (ICF) is found within
the cells of the body. It constitutes approximately two-thirds of
the total body fluid in adults. Extracellular fluid (ECF) is found
outside the cells and accounts for about one-third of total body
fluid. It is subdivided into compartments. The two main com-
partments of ECF are intravascular and interstitial. Intravascular
fluid, or plasma, accounts for approximately 20% of the ECF
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CHAPTER 52 / Fluid, Electrolyte, and AcidBase Balance 1425
and is found within the vascular system. Interstitial fluid, ac-
counting for approximately 75% of the ECF, surrounds the
cells. The other compartments of ECF are the lymph and trans-
cellular fluids. Examples of transcellular fluid include cere-
brospinal, pericardial, pancreatic, pleural, intraocular, biliary,
peritoneal, and synovial fluids (Figure 52-1 ).
Intracellular fluid is vital to normal cell functioning. It con-
tains solutes such as oxygen, electrolytes, and glucose, and it
provides a medium in which metabolic processes of the cell
take place.
Although extracellular fluid is in the smaller of the two
compartments, it is the transport system that carries nutrients
to and waste products from the cells. For example, plasma car-
ries oxygen from the lungs and glucose from the gastrointesti-
nal tract to the capillaries of the vascular system. From there,
the oxygen and glucose move across the capillary membranes
into the interstitial spaces and then across the cellular mem-
branes into the cells. The opposite route is taken for waste
products, such as carbon dioxide going from the cells to the
lungs and metabolic acid wastes going eventually to the kid-
neys. Interstitial fluid transports wastes from the cells by way
of the lymph system as well as directly into the blood plasma
through capillaries.
Composition of Body Fluids
Extracellular and intracellular fluids contain oxygen from the
lungs, dissolved nutrients from the gastrointestinal tract, excre-
tory products of metabolism such as carbon dioxide, and
charged particles called ions.
Total body fluid
40 liters
Cell fluid
25 liters
Plasma
3 liters
Interstitial and
transcellular fluid
12 liters
Extracellular
fluid
15 liters
Figure 52-1 Total body fluid represents 40 L in an adult male
weighing 70 kg (154 lb).
Many salts dissociate in water, that is, break up into electri-
cally charged ions. The salt sodium chloride breaks up into one
ion of sodium (Na
) and one ion of chloride (Cl
). These
charged particles are called electrolytes because they are capa-
ble of conducting electricity. The number of ions that carry a
positive charge, called cations, and ions that carry a negative
charge, called anions, should be equal. Examples of cations are
sodium (Na
), potassium (K
), calcium (Ca
2
), and magnesium
(Mg
2
). Examples of anions include chloride (Cl
), bicarbonate
HCO
3
, phosphate HPO
4
2
, and sulfate SO
4
2
.
Electrolytes generally are measured in milliequivalents per
liter of water (mEq/L) or milligrams per 100 milliliters
(mg/100 mL). The term milliequivalent refers to the chemical
combining power of the ion, or the capacity of cations to com-
bine with anions to formmolecules. This combining activity is
measured in relation to the combining activity of the hydrogen
ion (H
). Thus, 1 mEq of any anion equals 1 mEq of any

cation. For example, sodium and chloride ions are equivalent,
since they combine equally: 1 mEq of Na
equals 1 mEq of
Cl
. However, these cations and anions are not equal in

weight: 1 mg of Na
does not equal 1 mg of Cl
; rather, 3 mg
of Na
equals 2 mg of Cl
.
Clinically, the milliequivalent system is most often used.
However, nurses need to be aware that different systems of
measurement may be found when interpreting laboratory re-
sults. For example, calcium levels frequently are reported in
milligrams per deciliter (1 dL 100 mL) instead of milliequiv-
alents per liter. It also is important to remember that laboratory
tests are usually performed using blood plasma, an extracellular
fluid. These results may reflect what is happening in the ECF,
but it generally is not possible to directly measure electrolyte
concentrations within the cell.
The composition of fluids varies from one body compart-
ment to another. In extracellular fluid, the principal elec-
trolytes are sodium, chloride, and bicarbonate. Other
electrolytes such as potassium, calcium, and magnesium are
also present but in much smaller quantities. Plasma and inter-
stitial fluid, the two primary components of ECF, contain es-
sentially the same electrolytes and solutes, with the exception
of protein. Plasma is a protein-rich fluid, containing large
amounts of albumin, but interstitial fluid contains little or no
protein.
The composition of intracellular fluid differs significantly
from that of ECF. Potassium and magnesium are the primary
cations present in ICF, with phosphate and sulfate the major an-
ions. As in ECF, other electrolytes are present within the cell,
but in much smaller concentrations (Figure 52-2 ).
Maintaining a balance of fluid volumes and electrolyte com-
positions in the fluid compartments of the body is essential to
health. Normal and unusual fluid and electrolyte losses must be
replaced if homeostasis is to be maintained.
Other body fluids such as gastric and intestinal secretions
also contain electrolytes. This is of particular concern when
these fluids are lost from the body (for example, in severe vom-
iting or diarrhea or when gastric suction removes the gastric se-
cretions). Fluid and electrolyte imbalances can result from
excessive losses through these routes.
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Na
+
Na
+
Na
+
K
+
K
+
K
+
Mg
2+
Ca
2+
Plasma
Interstitial
fluid
Intracellular
fluid
0
50
100
150
200
CATIONS
HCO
3
HCO
3
HCO
3
HPO
4
2
HPO
4
2
HPO
4
2
SO
4
2
SO
4
2
Cl
Cl
Cl
Plasma
Interstitial
fluid
Intracellular
fluid
0
50
100
150
200
ANIONS
Org. acid
Proteins
Proteins
M
i
l
l
i
e
q
u
i
v
a
l
e
n
t
s

p
e
r

L
i
t
e
r

(
m
E
q
/
L
)
Figure 52-2 Electrolyte composition (cations and anions) of body fluid compartments.
Martini, Fredric H.; Halyard, Rebecca A., Fundamentals of Anatomy and Physiology Interactive, (Media Edition), 4th ed., 1998. Reproduced with permission of Pearson
Education, Inc., Upper Saddle River, New Jersey.
Higher concentration Lower concentration
Semipermeable
membrane
Dissolved
substances
Water
molecules
H
2
0
H
2
0
H
2
0
Figure 52-3 Osmosis: Water molecules move from the less
concentrated area to the more concentrated area in an attempt to
equalize the concentration of solutions on two sides of a membrane.
Movement of Body Fluids
and Electrolytes
The body fluid compartments are separated from one another by
cell membranes and the capillary membrane. While these mem-
branes are completely permeable to water, they are considered
to be selectively permeable to solutes as substances move across
them with varying degrees of ease. Small particles such as ions,
oxygen, and carbon dioxide easily move across these mem-
branes, but larger molecules like glucose and proteins have
more difficulty moving between fluid compartments.
The methods by which electrolytes and other solutes move
are osmosis, diffusion, filtration, and active transport.
Osmosis
Osmosis is the movement of water across cell membranes,
from the less concentrated solution to the more concentrated
solution (Figure 52-3 ). In other words, water moves toward
the higher concentration of solute in an attempt to equalize
the concentrations.
Solutes are substances dissolved in a liquid. For example,
when sugar is added to coffee, the sugar is the solute. Solutes
may be crystalloids (salts that dissolve readily into true solu-
tions) or colloids (substances such as large protein molecules
that do not readily dissolve into true solutions). Asolvent is the
component of a solution that can dissolve a solute. In the previ-
ous example, coffee is the solvent for the sugar.
In the body, water is the solvent; the solutes include elec-
trolytes, oxygen and carbon dioxide, glucose, urea, amino acids,
and proteins. Osmosis occurs when the concentration of solutes
on one side of a selectively permeable membrane, such as the
capillary membrane, is higher than on the other side. For exam-
ple, a marathon runner loses a significant amount of water
through perspiration, increasing the concentration of solutes in
the plasma because of water loss. This higher solute concentra-
tion draws water from the interstitial space and cells into the
vascular compartment to equalize the concentration of solutes
koz74686_ch52.qxd 11/21/06 1:08 PM Page 1426
in all fluid compartments. Osmosis is an important mechanism
for maintaining homeostasis and fluid balance.
The concentration of solutes in body fluids is usually ex-
pressed as the osmolality. Osmolality is determined by the total
solute concentration within a fluid compartment and is mea-
sured as parts of solute per kilogram of water.
Osmolality is reported as milliosmols per kilogram (mOsm/
kg). Sodium is by far the greatest determinant of serum osmolality,
with glucose and urea also contributing. Potassium, glucose, and
urea are the primary contributors to the osmolality of intracellular
fluid. The term tonicity may be used to refer to the osmolality of a
solution. Solutions may be termed isotonic, hypertonic, or hypo-
tonic. An isotonic solution has the same osmolality as body fluids.
Normal saline, 0.9% sodium chloride, is an isotonic solution. Hyp-
ertonic solutions have a higher osmolality than body fluids; 3%
sodium chloride is a hypertonic solution. Hypotonic solutions such
as one-half normal saline (0.45% sodium chloride), by contrast,
have a lower osmolality than body fluids.
Osmotic pressure is the power of a solution to draw water
across a semipermeable membrane. When two solutions of dif-
ferent solute concentrations are separated by a semipermeable
membrane, the solution of higher solute concentration exerts a
higher osmotic pressure, drawing water across the membrane to
equalize the concentrations of the solutions. For example, infus-
ing a hypertonic intravenous solution such as 3% sodium chlo-
ride will draw fluid out of red blood cells (RBCs), causing them
to shrink. On the other hand, a hypotonic solution administered
intravenously will cause the RBCs to swell as water is drawn
into the cells by their higher osmotic pressure. In the body,
plasma proteins exert an osmotic draw called colloid osmotic
pressure or oncotic pressure, pulling water from the interstitial
space into the vascular compartment. This is an important
mechanism in maintaining vascular volume.
Diffusion
Diffusion is the continual intermingling of molecules in liquids,
gases, or solids brought about by the random movement of the
molecules. For example, two gases become mixed by the con-
stant motion of their molecules. The process of diffusion occurs
even when two substances are separated by a thin membrane. In
the body, diffusion of water, electrolytes, and other substances
occurs through the split pores of capillary membranes.
The rate of diffusion of substances varies according to (a) the
size of the molecules, (b) the concentration of the solution, and
(c) the temperature of the solution. Larger molecules move less
Higher concentration Lower concentration
Dissolved
substance
Semipermeable
membrane
Figure 52-4 Diffusion: The movement of molecules through a
semipermeable membrane from an area of higher concentration to an
area of lower concentration.
quickly than smaller ones because they require more energy to
move about. With diffusion, the molecules move from a solu-
tion of higher concentration to a solution of lower concentration
(Figure 52-4 ). Increases in temperature increase the rate of
motion of molecules and therefore the rate of diffusion.
Filtration
Filtration is a process whereby fluid and solutes move together
across a membrane from one compartment to another. The
movement is from an area of higher pressure to one of lower
pressure. An example of filtration is the movement of fluid and
nutrients from the capillaries of the arterioles to the interstitial
fluid around the cells. The pressure in the compartment that re-
sults in the movement of the fluid and substances dissolved in
fluid out of the compartment is called filtration pressure.
Hydrostatic pressure is the pressure exerted by a fluid within a
closed system on the walls of a container in which it is contained.
The hydrostatic pressure of blood is the force exerted by blood
against the vascular walls (e.g., the artery walls). The principle
involved in hydrostatic pressure is that fluids move from the area
of greater pressure to the area of lesser pressure. Using the ex-
ample of the blood vessels, the plasma proteins in the blood ex-
ert a colloid osmotic or oncotic pressure (see the earlier section
Osmosis) that opposes the hydrostatic pressure and holds the
fluid in the vascular compartment to maintain the vascular vol-
ume. When the hydrostatic pressure is greater than the osmotic
pressure, the fluid filters out of the blood vessels. The filtration
pressure in this example is the difference between the hydrostatic
pressure and the osmotic pressure (Figure 52-5 ).
Arterial side of capillary bed
Interstitial
space
Venous side of capillary bed
Direction of filtration
fluid and solutes
Direction of filtration
fluid and solutes
Capillary bed
Hydrostatic pressure
(arterial blood pressure)
Hydrostatic pressure
(venous blood pressure)
Colloid osmotic pressure
(constant throughout
capillary bed)
Figure 52-5 Schematic of filtration pressure
changes within a capillary bed. On the arterial side,
arterial blood pressure exceeds colloid osmotic
pressure, so that water and dissolved substances
move out of the capillary into the interstitial space. On
the venous side, venous blood pressure is less than
colloid osmotic pressure, so that water and dissolved
substances move into the capillary.
M
e
d
i
a
L
i
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k

M
e
m
b
r
a
n
e

T
r
a
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A
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koz74686_ch52.qxd 11/8/06 2:06 PM Page 1427
Intracellular fluid Extracellular fluid
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
Na
+
K
+
Na
+
K
+
K
+
K
+
K
+
K
+
K
+
K
+
K
+
K
+
K
+
K
+
K
+
K
+
K
+
K
+
Cell membrane
ATP
ATP
ATP
ATP
Figure 52-6 An example of active transport. Energy (ATP) is used to
move sodium molecules and potassium molecules across a
semipermeable membrane against sodiums and potassiums
concentration gradients (i.e., from areas of lesser concentration to
areas of greater concentration).
Active Transport
Substances can move across cell membranes from a less con-
centrated solution to a more concentrated one by active trans-
port (Figure 52-6 ). This process differs from diffusion and
osmosis in that metabolic energy is expended. In active trans-
port, a substance combines with a carrier on the outside surface
of the cell membrane, and they move to the inside surface of the
cell membrane. Once inside, they separate, and the substance is
released to the inside of the cell. Aspecific carrier is required for
each substance, enzymes are required for active transport, and
energy is expended.
This process is of particular importance in maintaining the
differences in sodium and potassium ion concentrations of
ECF and ICF. Under normal conditions, sodium concentra-
tions are higher in the extracellular fluid, and potassium con-
centrations are higher inside the cells. To maintain these
proportions, the active transport mechanism (the sodium-
potassium pump) is activated, moving sodium from the cells
and potassium into the cells.
Regulating Body Fluids
In a healthy person, the volumes and chemical composition of
the fluid compartments stay within narrow safe limits. Nor-
mally fluid intake and fluid loss are balanced. Illness can upset
this balance so that the body has too little or too much fluid.
Fluid Intake
During periods of moderate activity at moderate temperature, the
average adult drinks about 1,500 mL per day but needs 2,500 mL
per day, an additional 1,000 mL. This added volume is acquired
from foods and from the oxidation of these foods during metabolic
processes. Interestingly, the water content of food is relatively
large, contributing about 750 mL per day. The water content of
fresh vegetables is approximately 90%, of fresh fruits about 85%,
and of lean meats around 60%.
Water as a by-product of food metabolism accounts for most
of the remaining fluid volume required. This quantity is approx-
imately 200 mL per day for the average adult. See Table 521.
The thirst mechanism is the primary regulator of fluid intake.
The thirst center is located in the hypothalamus of the brain. A
number of stimuli trigger this center, including the osmotic
pressure of body fluids, vascular volume, and angiotensin (a
hormone released in response to decreased blood flow to the
kidneys). For example, a long-distance runner loses significant
amounts of water through perspiration and rapid breathing dur-
ing a race, increasing the concentration of solutes and the os-
motic pressure of body fluids. This increased osmotic pressure
stimulates the thirst center, causing the runner to experience the
sensation of thirst and the desire to drink to replace lost fluids.
Thirst is normally relieved immediately after drinking a
small amount of fluid, even before it is absorbed from the gas-
trointestinal tract. However, this relief is only temporary, and
the thirst returns in about 15 minutes. The thirst is again tem-
porarily relieved after the ingested fluid distends the upper gas-
trointestinal tract. These mechanisms protect the individual
from drinking too much, because it takes from 30 minutes to 1
hour for the fluid to be absorbed and distributed throughout the
body. See Figure 52-7
.
Fluid Output
Fluid losses from the body counterbalance the adults 2,500-mL
average daily intake of fluid, as shown in Table 522. There are
four routes of fluid output:
1. Urine
2. Insensible loss through the skin as perspiration and through
the lungs as water vapor in the expired air
3. Noticeable loss through the skin
4. Loss through the intestines in feces
URINE. Urine formed by the kidneys and excreted from the uri-
nary bladder is the major avenue of fluid output. Normal urine
output for an adult is 1,400 to 1,500 mL per 24 hours, or at least
0.5 mL per kilogram per hour. In healthy people, urine output
may vary noticeably from day to day. Urine volume automati-
cally increases as fluid intake increases. If fluid loss through per-
spiration is large, however, urine volume decreases to maintain
fluid balance in the body.
INSENSIBLE LOSSES. Insensible fluid loss occurs through the
skin and lungs. It is called insensible because it is usually not no-
ticeable and cannot be measured. Insensible fluid loss through
TABLE 521 Average Daily Fluid Intake
for an Adult
SOURCE AMOUNT (ML)
Oral fluids 1,200 to 1,500
Water in foods 1,000
Water as by-product of 200
food metabolism
Total 2,400 to 2,700
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the skin occurs in two ways. Water is lost through diffusion and
through perspiration (which is noticeable but not measurable).
Water losses through diffusion are not noticeable but normally
account for 300 to 400 mLper day. This loss can be significantly
increased if the protective layer of the skin is lost as with burns
or large abrasions. Perspiration varies depending on factors such
as environmental temperature and metabolic activity. Fever and
exercise increase metabolic activity and heat production, thereby
increasing fluid losses through the skin.
Another type of insensible loss is the water in exhaled air. In
an adult, this is normally 300 to 400 mL per day. When respira-
tory rate accelerates, for example, due to exercise or an elevated
body temperature, this loss can increase.
FECES. The chyme that passes from the small intestine into the
large intestine contains water and electrolytes. The volume of
chyme entering the large intestine in an adult is normally about
1,500 mL per day. Of this amount, all but about 100 mL is reab-
sorbed in the proximal half of the large intestine.
Certain fluid losses are required to maintain normal body
function. These are known as obligatory losses. Approximately
500 mL of fluid must be excreted through the kidneys of an
adult each day to eliminate metabolic waste products from the
body. Water lost through respirations, through the skin, and in
feces also are obligatory losses, necessary for temperature reg-
ulation and elimination of waste products. The total of all these
losses is approximately 1,300 mL per day.
Maintaining Homeostasis
The volume and composition of body fluids is regulated through
several homeostatic mechanisms. Anumber of body systems con-
tribute to this regulation, including the kidneys, the endocrine sys-
tem, the cardiovascular system, the lungs, and the gastrointestinal
system. Hormones such as antidiuretic hormone (ADH; also
known as arginine vasopressin or AVP), the renin-angiotensin-
aldosterone system, and atrial natriuretic factor are involved, as
are mechanisms to monitor and maintain vascular volume.
KIDNEYS. The kidneys are the primary regulator of body fluids
and electrolyte balance. They regulate the volume and osmolal-
ity of extracellular fluids by regulating water and electrolyte ex-
cretion. The kidneys adjust the reabsorption of water from
plasma filtrate and ultimately the amount excreted as urine. Al-
though 135 to 180 L of plasma per day is normally filtered in an
adult, only about 1.5 L of urine is excreted. Electrolyte balance
is maintained by selective retention and excretion by the kid-
neys. The kidneys also play a significant role in acidbase regu-
lation, excreting hydrogen ion (H
) and retaining bicarbonate.

ANTIDIURETIC HORMONE. Antidiuretic hormone, which regu-
lates water excretion from the kidney, is synthesized in the ante-
rior portion of the hypothalamus and acts on the collecting ducts
of the nephrons. When serum osmolality rises, ADH is produced,
causing the collecting ducts to become more permeable to water.
This increased permeability allows more water to be reabsorbed
into the blood. As more water is reabsorbed, urine output falls
and serum osmolality decreases because the water dilutes body
fluids. Conversely, if serum osmolality decreases, ADH is sup-
pressed, the collecting ducts become less permeable to water,
and urine output increases. Excess water is excreted, and serum
osmolality returns to normal. Other factors also affect the pro-
duction and release of ADH, including blood volume, tempera-
ture, pain, stress, and some drugs such as opiates, barbiturates,
and nicotine. See Figure 52-8 .
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM. Specialized
receptors in the juxtaglomerular cells of the kidney nephrons re-
spond to changes in renal perfusion. This initiates the renin-
angiotensin-aldosterone system. If blood flow or pressure to the
kidney decreases, renin is released. Renin causes the conversion
of angiotensinogen to angiotensin I, which is then converted to
angiotensin II by angiotensin-converting enzyme. Angiotensin II
Increased volume
of extracellular fluid
and
and
Decreased volume
Decreased osmolality
Stimulates osmoreceptors
in hypothalamic
thirst center
Decreased saliva secretion
Water absorbed from
gastrointestinal tract
Dry mouth
Increased osmolality
Sensation of thirst:
person seeks a drink
Figure 52-7 Factors stimulating water intake through the thirst
mechanism.
From Lemone, Priscilla; Burke, Karen M., Medical Surgical Nursing: Critical Thinking in
Client Care, 3rd ed 2004. Reproduced with permission of Pearson Education, Inc.,
Upper Saddle River, New Jersey.
TABLE 522 Average Daily Fluid Output
for an Adult
ROUTE AMOUNT (ML)
Urine 1,400 to 1,500
Insensible losses
Lungs 350 to 400
Skin 350 to 400
Sweat 100
Feces 100 to 200
Total 2,300 to 2,600
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acts directly on the nephrons to promote sodium and water reten-
tion. In addition, it stimulates the release of aldosterone from
the adrenal cortex. Aldosterone also promotes sodium retention
in the distal nephron. The net effect of the renin-angiotensin-
aldosterone system is to restore blood volume (and renal perfu-
sion) through sodium and water retention.
ATRIAL NATRIURETIC FACTOR. Atrial natriuretic factor (ANF)
is released from cells in the atrium of the heart in response to ex-
cess blood volume and stretching of the atrial walls. Acting on
the nephrons, ANF promotes sodium wasting and acts as a po-
tent diuretic, thus reducing vascular volume. ANF also inhibits
thirst, reducing fluid intake.
Regulating Electrolytes
Electrolytes, charged ions capable of conducting electricity, are
present in all body fluids and fluid compartments. Just as main-
taining the fluid balance is vital to normal body function, so is
maintaining electrolyte balance. Although the concentration of
specific electrolytes differs between fluid compartments, a bal-
ance of cations (positively charged ions) and anions (negatively
charged ions) always exists. Electrolytes are important for
Maintaining fluid balance.
Contributing to acidbase regulation.
Facilitating enzyme reactions.
Transmitting neuromuscular reactions.
Most electrolytes enter the body through dietary intake and
are excreted in the urine. Some electrolytes, such as sodium and
chloride, are not stored by the body and must be consumed daily
to maintain normal levels. Potassium and calcium, on the other
hand, are stored in the cells and bone, respectively. When serum
levels drop, ions can shift out of the storage pool into the
blood to maintain adequate serum levels for normal function-
ing. The regulatory mechanisms and functions of the major
electrolytes are summarized in Table 523.
Urine output
Serum/blood osmolality as
the water dilutes body fluids
Osmoreceptors in
hypothalamus
stimulate posterior
pituitary to secrete ADH
ADH increases
distal tubule
permeability
Reabsorption
of H
2
O
into blood
blood osmolality
Urine output
Serum osmolality
returns to normal
ADH is suppressed
ADH causes distal
tubules to become
less permeable
to water
Reabsorption
of H
2
O
into blood
blood osmolality
Figure 52-8 Antidiuretic hormone (ADH) regulates water excretion from the kidneys.
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Sodium (Na
)
Sodium is the most abundant cation in extracellular fluid and a
major contributor to serum osmolality. Normal serum sodium
levels are 135 to 145 mEq/L. Sodium functions largely in con-
trolling and regulating water balance. When sodium is reab-
sorbed from the kidney tubules, chloride and water are
reabsorbed with it, thus maintaining ECF volume. Sodium is
found in many foods, such as bacon, ham, processed cheese,
and table salt.
Potassium (K
)
Potassium is the major cation in intracellular fluids, with only
a small amount found in plasma and interstitial fluid. ICF lev-
els of potassium are usually 125 to 140 mEq/L while normal
serum potassium levels are 3.5 to 5.0 mEq/L. The ratio of in-
tracellular to extracellular potassium must be maintained for
neuromuscular response to stimuli. Potassium is a vital elec-
trolyte for skeletal, cardiac, and smooth muscle activity. It is
involved in maintaining acidbase balance as well, and it con-
tributes to intracellular enzyme reactions. Potassium must be
ingested daily because the body cant conserve it. Many fruits
and vegetables, meat, fish, and other foods contain potassium
(see Box 521).
Calcium (Ca
2
)
The vast majority, 99%, of calcium in the body is in the skele-
tal system, with a relatively small amount in extracellular fluid.
Although this calcium outside the bones and teeth amounts to
only about 1% of the total calcium in the body, it is vital in reg-
ulating muscle contraction and relaxation, neuromuscular func-
tion, and cardiac function. ECF calcium is regulated by a
complex interaction of parathyroid hormone, calcitonin, and
calcitriol, a metabolite of vitamin D. When calcium levels in the
TABLE 523 Regulation and Functions of Electrolytes
ELECTROLYTE REGULATION FUNCTION
Sodium (Na
)
Potassium (K
)
Calcium (Ca
2
)
Magnesium (Mg
2
)
Chloride (Cl
)
Phosphate (PO
4
)
Bicarbonate (HCO
3
)
Regulating ECF volume and distribution
Maintaining blood volume
Transmitting nerve impulses and contracting muscles
Maintaining ICF osmolality
Transmitting nerve and other electrical impulses
Regulating cardiac impulse transmission and muscle
contraction
Skeletal and smooth muscle function
Regulating acidbase balance
Forming bones and teeth
Transmitting nerve impulses
Regulating muscle contractions
Maintaining cardiac pacemaker (automaticity)
Blood clotting
Activating enzymes such as pancreatic lipase and
phospholipase
Intracellular metabolism
Operating sodium-potassium pump
Relaxing muscle contractions
Transmitting nerve impulses
Regulating cardiac function
HCl production
Regulating ECF balance and vascular volume
Buffer in oxygencarbon dioxide exchange in RBCs
Forming bones and teeth
Metabolizing carbohydrate, protein, and fat
Cellular metabolism; producing ATP and DNA
Muscle, nerve, and RBC function
Regulating calcium levels
Major body buffer involved in acidbase regulation
Renal reabsorption or excretion
Aldosterone increases Na
reabsorption in collecting
duct of nephrons
Renal excretion and conservation
Aldosterone increases K
excretion
Movement into and out of cells
Insulin helps move K
into cells; tissue damage and

acidosis shift K
out of cells into ECF

Redistribution between bones and ECF
Parathyroid hormone and calcitriol increase serum
Ca
2
levels; calcitonin decreases serum levels
Conservation and excretion by kidneys
Intestinal absorption increased by vitamin D and
parathyroid hormone
Excreted and reabsorbed along with sodium in the
kidneys
Aldosterone increases chloride reabsorption with
sodium
Excretion and reabsorption by the kidneys
Parathyroid hormone decreases serum levels by
increasing renal excretion
Reciprocal relationship with calcium: increasing serum
calcium levels decrease phosphate levels; decreasing
serum calcium increases phosphate
Excretion and reabsorption by the kidneys
Regeneration by kidneys
BOX 521 Potassium-Rich Foods
VEGETABLES
Avocado
Raw carrot
Baked potato
Raw tomato
Spinach
MEATS AND FISH
Beef
Cod
Pork
Veal
FRUITS
Dried fruits (e.g., raisins and dates)
Banana
Apricot
Cantaloupe
Orange
BEVERAGES
Milk
Orange juice
Apricot nectar
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ECF fall, parathyroid hormone and calcitriol cause calcium to
be released from bones into ECF and increase the absorption of
calcium in the intestines, thus raising serum calcium levels.
Conversely, calcitonin stimulates the deposition of calcium in
bone, reducing the concentration of calcium ions in the blood.
With aging, the intestines absorb calcium less effectively and
more calcium is excreted via the kidneys. Calcium shifts out of
the bone to replace these ECF losses, increasing the risk of os-
teoporosis and fractures of the wrists, vertebrae, and hips. Lack
of weight-bearing exercise (which helps keep calcium in the
bones) and a vitamin D deficiency because of inadequate expo-
sure to sunlight contribute to this risk.
Milk and milk products are the richest sources of calcium,
with other foods such as dark green leafy vegetables and canned
salmon containing smaller amounts. Many clients benefit from
calcium supplements.
Serum calcium levels are often reported in two ways, based
upon the way it is circulating in the plasma. Approximately 50%
of serum calcium circulates in a free, ionized, or unbound form.
The other 50% circulates in the plasma bound to either plasma
proteins or other nonprotein ions. The normal total serum cal-
ciumlevels, which range from8.5 to 10.5 mg/dL, represent both
bound and unbound calcium. The normal ionized serumcalcium,
which ranges from4.0 to 5.0 mg/dL, represents calciumcirculat-
ing in the plasma in free, or unbound, form(Hayes, 2004).
Magnesium (Mg
2
)
Magnesium is primarily found in the skeleton and in intracellu-
lar fluid. It is the second most abundant intracellular cation with
normal serum levels of 1.5 to 2.5 mEq/L. It is important for in-
tracellular metabolism, being particularly involved in the pro-
duction and use of ATP. Magnesium also is necessary for protein
and DNA synthesis within the cells. Only about 1% of the
bodys magnesium is in ECF; here it is involved in regulating
neuromuscular and cardiac function. Maintaining and ensuring
adequate magnesium levels is an important part of care of
clients with cardiac disorders. Cereal grains, nuts, dried fruit,
legumes, and green leafy vegetables are good sources of mag-
nesium in the diet, as are dairy products, meat, and fish.
Chloride (Cl
)
Chloride is the major anion of ECF, and normal serum levels are
95 to 108 mEq/L. Chloride functions with sodium to regulate
serum osmolality and blood volume. The concentration of chlo-
ride in ECF is regulated secondarily to sodium; when sodium is
reabsorbed in the kidney, chloride usually follows. Chloride is a
major component of gastric juice as hydrochloric acid (HCl)
and is involved in regulating acidbase balance. It also acts as a
buffer in the exchange of oxygen and carbon dioxide in RBCs.
Chloride is found in the same foods as sodium.
Phosphate PO
4
Phosphate is the major anion of intracellular fluids. It also is

found in ECF, bone, skeletal muscle, and nerve tissue. Normal
serum levels of phospate in adults range from 2.5 to 4.5 mg/dL.
Children have much higher phosphate levels than adults, with
that of a newborn nearly twice that of an adult. Higher levels of
growth hormone and a faster rate of skeletal growth probably
account for this difference. Phosphate is involved in many
chemical actions of the cell; it is essential for functioning of
muscles, nerves, and red blood cells. It is also involved in the
metabolism of protein, fat, and carbohydrate. Phosphate is ab-
sorbed from the intestine and is found in many foods such as
meat, fish, poultry, milk products, and legumes.
Bicarbonate HCO
3
Bicarbonate is present in both intracellular and extracellular flu-

ids. Its primary function is regulating acidbase balance as an
essential component of the carbonic acidbicarbonate buffering
system. Extracellular bicarbonate levels are regulated by the
kidneys: Bicarbonate is excreted when too much is present; if
more is needed, the kidneys both regenerate and reabsorb bicar-
bonate ions. Unlike other electrolytes that must be consumed in
the diet, adequate amounts of bicarbonate are produced through
metabolic processes to meet the bodys needs.
ACIDBASE BALANCE
An important part of regulating the chemical balance or home-
ostasis of body fluids is regulating their acidity or alkalinity. An
acid is a substance that releases hydrogen ions (H
) in solution.
Strong acids such as hydrochloric acid release all or nearly all
their hydrogen ions; weak acids like carbonic acid release some
hydrogen ions. Bases or alkalis have a low hydrogen ion con-
centration and can accept hydrogen ions in solution. The rela-
tive acidity or alkalinity of a solution is measured as pH. The pH
reflects the hydrogen ion concentration of the solution: The
higher the hydrogen ion concentration (and the more acidic the
solution), the lower the pH. Water has a pH of 7 and is neutral;
that is, it is neither acidic in nature nor is it alkaline. Solutions
with a pH lower than 7 are acidic; those with a pH higher than
7 are alkaline. The pH scale is logarithmic: Asolution with a pH
of 5 is 10 times more acidic than one with a pH of 6.
Regulation of AcidBase Balance
Body fluids are maintained within a narrow range that is slightly
alkaline. The normal pH of arterial blood is between 7.35 and
7.45 (Figure 52-9 ). Acids are continually produced during me-
Death Acidosis Normal Alkalosis Death
6.8 7.35 7.45 7.8
1 7 14
Alkaline
solution
(low H
+
)
Neutral
pH scale
pH
Acidic
solution
(high H
+
)
Figure 52-9 Body fluids are normally slightly alkaline, between a pH
of 7.35 and 7.45.
koz74686_ch52.qxd 11/8/06 2:06 PM Page 1432
tabolism. Several body systems, including buffers, the respira-
tory system, and the renal system, are actively involved in main-
taining the narrow pH range necessary for optimal function.
Buffers help maintain acidbase balance by neutralizing excess
acids or bases. The lungs and the kidneys help maintain a nor-
mal pH by either excreting or retaining acids and bases.
Buffers
Buffers prevent excessive changes in pH by removing or releas-
ing hydrogen ions. If excess hydrogen ion is present in body flu-
ids, buffers bind with the hydrogen ion, minimizing the change
in pH. When body fluids become too alkaline, buffers can re-
lease hydrogen ion, again minimizing the change in pH. The ac-
tion of a buffer is immediate, but limited in its capacity to
maintain or restore normal acidbase balance.
The major buffer system in extracellular fluids is the bicarbon-
ate (HCO
3
) and carbonic acid (H

2
CO
3
) system. When a strong
acid such as hydrochloric acid (HCl) is added, it combines with bi-
carbonate and the pH drops only slightly. A strong base such as
sodium hydroxide combines with carbonic acid, the weak acid of
the buffer pair, and the pH remains within the narrow range of nor-
mal. The amounts of bicarbonate and carbonic acid in the body
vary; however, as long as a ratio of 20 parts of bicarbonate to 1 part
of carbonic acid is maintained, the pH remains within its normal
range of 7.35 to 7.45 (Figure 52-10
). Adding a strong acid to
ECF can change this ratio as bicarbonate is depleted in neutraliz-
ing the acid. When this happens, the pH drops, and the client has
a condition called acidosis. The ratio can also be upset by adding
a strong base to ECF, depleting carbonic acid as it combines with
the base. In this case the pH rises and the client has alkalosis.
In addition to the bicarbonatecarbonic acid buffer system,
plasma proteins, hemoglobin, and phosphates also function as
buffers in body fluids.
Respiratory Regulation
The lungs help regulate acidbase balance by eliminating or re-
taining carbon dioxide (CO
2
), a potential acid. Combined with
water, carbon dioxide forms carbonic acid (CO
2
H
2
O
H
2
CO
3
). This chemical reaction is reversible; carbonic acid
breaks down into carbon dioxide and water. Working together
with the bicarbonatecarbonic acid buffer system, the lungs reg-
ulate acidbase balance and pH by altering the rate and depth of
respirations. The response of the respiratory system to changes
in pH is rapid, occurring within minutes.
Carbon dioxide is a powerful stimulator of the respiratory
center. When blood levels of carbonic acid and carbon dioxide
rise, the respiratory center is stimulated and the rate and depth
of respirations increase. Carbon dioxide is exhaled, and car-
bonic acid levels fall. By contrast, when bicarbonate levels are
excessive, the rate and depth of respirations are reduced. This
causes carbon dioxide to be retained, carbonic acid levels to
rise, and the excess bicarbonate to be neutralized.
Carbon dioxide levels in the blood are measured as the
PCO
2
, or partial pressure of the dissolved gas in the blood.
PCO
2
refers to the pressure of carbon dioxide in venous blood.
PaCO
2
refers to the pressure of carbon dioxide in arterial blood.
The normal PaCO
2
is 35 to 45 mm Hg.
Renal Regulation
Although buffers and the respiratory system can compensate for
changes in pH, the kidneys are the ultimate long-term regulator
of acidbase balance. They are slower to respond to changes, re-
quiring hours to days to correct imbalances, but their response
is more permanent and selective than that of the other systems
(Yucha, 2004).
The kidneys maintain acidbase balance by selectively ex-
creting or conserving bicarbonate and hydrogen ions. When ex-
cess hydrogen ion is present and the pH falls (acidosis), the
kidneys reabsorb and regenerate bicarbonate and excrete hydro-
gen ion. In the case of alkalosis and a high pH, excess bicarbon-
ate is excreted and hydrogen ion is retained. The normal serum
bicarbonate level is 22 to 26 mEq/L.
The relationship of the respiratory and renal regulation of
acidbase balance is further explained in Box 522.
1 part
carbonic
acid or
1.2 mEq/L
20 parts
bicarbonate
or
24 mEq/L
6.8 7.35 7.45 7.8
Normal Acidosis Death Death Alkalosis
Figure 52-10 Carbonic acidbicarbonate ratio and pH.
BOX 522 Physiological Regulation
of AcidBase Balance
Lungs Kidneys
CO
2
H
2
O H
2
CO
3
H HCO
3
Carbon dioxide Hydrogen
Carbonic acid
water bicarbonate
The lungs and kidneys are the two major systems that are working on
a continuous basis to help regulate the acidbase balance in the body.
In the biochemical reactions above, the processes are all reversible and
go back and forth as the bodys needs change. The lungs can work very
quickly and do their part by either retaining or getting rid of carbon diox-
ide by changing the rate and depth of respirations. The kidneys work
much more slowly; they may take hours to days to regulate the bal-
ance by either excreting or conserving hydrogen and bicarbonate ions.
Under normal conditions, the two systems work together to maintain
homeostasis.
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FACTORS AFFECTING BODY FLUID,
ELECTROLYTES, AND
ACIDBASE BALANCE
The ability of the body to adjust fluids, electrolytes, and
acidbase balance is influenced by age, gender and body size,
environmental temperature, and lifestyle.
Age
Infants and growing children have much greater fluid turnover
than adults because their higher metabolic rate increases fluid
loss. Infants lose more fluid through the kidneys because imma-
ture kidneys are less able to conserve water than adult kidneys.
In addition, infants respirations are more rapid and the body
surface area is proportionately greater than that of adults, in-
creasing insensible fluid losses. The more rapid turnover of
fluid plus the losses produced by disease can create critical fluid
imbalances in children much more rapidly than in adults.
In elderly people, the normal aging process may affect fluid
balance. The thirst response often is blunted. Antidiuretic hor-
mone levels remain normal or may even be elevated, but the
nephrons become less able to conserve water in response to
ADH. Increased levels of atrial natriuretic factor seen in older
adults may also contribute to this impaired ability to conserve
water. These normal changes of aging increase the risk of dehy-
dration. When combined with the increased likelihood of heart
diseases, impaired renal function, and multiple drug regimens,
the older adults risk for fluid and electrolyte imbalance is sig-
nificant. Additionally, it is important to consider that the older
adult has thinner, more fragile skin and veins, which can make
an intravenous insertion more difficult.
Gender and Body Size
Total body water also is affected by gender and body size. Be-
cause fat cells contain little or no water, and lean tissue has a
high water content, people with a higher percentage of body fat
have less body fluid. Women have proportionately more body
fat and less body water than men. Water accounts for approxi-
mately 60% of an adult mans weight, but only 52% for an adult
woman. In an obese individual this may be even less, with wa-
ter responsible for only 30% to 40% of the persons weight.
Environmental Temperature
People with an illness and those participating in strenuous ac-
tivity are at risk for fluid and electrolyte imbalances when the
environmental temperature is high. Fluid losses through sweat-
ing are increased in hot environments as the body attempts to
dissipate heat. These losses are even greater in people who have
not been acclimatized to the environment.
Both salt and water are lost through sweating. When only
water is replaced, salt depletion is a risk. The person who is salt
depleted may experience fatigue, weakness, headache, and gas-
trointestinal symptoms such as anorexia and nausea. The risk of
adverse effects is even greater if lost water is not replaced. Body
temperature rises, and the person is at risk for heat exhaustion
or heatstroke. Heatstroke may occur in older adults or ill people
during prolonged periods of heat; it can also affect athletes and
LIFESPAN CONSIDERATIONS Fluid and Electrolyte Imbalance
INFANTS AND CHILDREN
Infants are at high risk for fluid and electrolyte imbalance because
Their immature kidneys cannot concentrate urine.
They have a rapid respiratory rate and proportionately larger body
surface area than adults, leading to greater insensate loss through
the skin and respirations.
They cannot express thirst, nor actively seek fluids.
Vomiting and/or diarrhea in infants and young children can lead
quickly to electrolyte imbalance. Oral rehydration therapy (ORT) (e.g.,
electrolyte solutions such as Pedialyte) should be used to restore fluid
and electrolyte balance in mild to moderate dehydration (American
Medical Association et al., 2004). Prompt treatment with ORT can pre-
vent the need for intravenous therapy and hospitalization (Spandor-
fer, Alessandrini, Joffe, Localio, & Shaw, 2005). Even if the child is
nauseated and vomiting, small sips of ORT can be helpful.
ELDERS
Certain changes related to aging place the elder at risk for serious
problems with fluid and electrolyte imbalance, if homeostatic mecha-
nisms are compromised. Some of the changes are
A decrease in thirst sensation.
A decrease in ability of the kidneys to concentrate urine.
A decrease in intracellular fluid and in total body water.
A decrease in response to body hormones that help regulate fluid
and electrolytes.
Other factors that may influence fluid and electrolyte balance in
elders are
Increased use of diuretics for hypertension and heart disease.
Decreased intake of food and water, especially in elders with de-
mentia or who are dependent on others to feed them and offer
them fluids.
Preparations for certain diagnostic tests that have the client NPO
for long periods of time or cause diarrhea from laxative preps.
Clients with impaired renal function, such as elders with diabetes.
Those having certain diagnostic procedures. (Dyes used for some
procedures, such as arteriograms and cardiac catheterizations,
may cause further renal problems. Always see that the client is well
hydrated before, during, and after the procedure to help in diluting
and excreting the dye. If the client is NPO for the procedure, the
nurse should check with the primary care provider to see if IV flu-
ids are needed.)
Any condition that may tax the normal compensatory mecha-
nisms, such as a fever, influenza, surgery, or heat exposure.
All of these conditions increase elders risk for fluid and electrolyte
imbalance. The change can happen quickly and become serious in a
short time. Astute observations and quick actions by the nurse can
help prevent serious consequences. A change in mental status may
be the first symptom of impairment and must be further evaluated to
determine the cause.
koz74686_ch52.qxd 11/8/06 2:06 PM Page 1434
laborers when their heat production exceeds the bodys ability
to dissipate heat.
Consuming adequate amounts of cool liquids, particularly dur-
ing strenuous activity, reduces the risk of adverse effects from
heat. Balanced electrolyte solutions and carbohydrate-electrolyte
solutions such as sports drinks are recommended because they
replace both water and electrolytes lost through sweat.
Lifestyle
Other factors such as diet, exercise, and stress affect fluid, elec-
trolyte, and acidbase balance.
The intake of fluids and electrolytes is affected by the diet.
People with anorexia nervosa or bulimia are at risk for severe
fluid and electrolyte imbalances because of inadequate intake or
purging regimens (e.g., induced vomiting, use of diuretics and
laxatives). Seriously malnourished people have decreased
serum albumin levels, and may develop edema because the os-
motic draw of fluid into the vascular compartment is reduced.
When calorie intake is not adequate to meet the bodys needs,
fat stores are broken down and fatty acids are released, increas-
ing the risk of acidosis.
Regular weight-bearing physical exercise such as walking,
running, or bicycling has a beneficial effect on calcium balance.
The rate of bone loss that occurs in postmenopausal women and
older men is slowed with regular exercise, reducing the risk of
osteoporosis.
Stress can increase cellular metabolism, blood glucose con-
centration, and catecholamine levels. In addition, stress can in-
crease production of ADH, which in turn decreases urine
production. The overall response of the body to stress is to in-
crease the blood volume.
Other lifestyle factors can also affect fluid, electrolyte, and
acidbase balance. Heavy alcohol consumption affects elec-
trolyte balance, increasing the risk of low calcium, magnesium,
and phosphate levels. The risk of acidosis associated with
breakdown of fat tissue also is greater in the person who drinks
large amounts of alcohol.
DISTURBANCES IN FLUID
VOLUME, ELECTROLYTE,
AND ACIDBASE BALANCES
A number of factors such as illness, trauma, surgery, and med-
ications can affect the bodys ability to maintain fluid, elec-
trolyte, and acidbase balance. The kidneys play a major role in
maintaining fluid, electrolyte, and acidbase balance, and renal
disease is a significant cause of imbalance. Clients who are con-
fused or unable to communicate their needs are at risk for inad-
equate fluid intake. Vomiting, diarrhea, or nasogastric suction
can cause significant fluid losses. Tissue trauma, such as burns,
causes fluid and electrolytes to be lost from damaged cells. De-
creased blood flow to the kidneys due to impaired cardiac func-
tion stimulates the renin-angiotensin-aldosterone system,
causing sodium and water retention. Medications such as di-
uretics or corticosteroids can result in abnormal losses of elec-
trolytes and fluid loss or retention. Diseases such as diabetes
mellitus or chronic obstructive lung disease may affect
acidbase balance. Diabetic ketoacidosis, cancer, and head in-
jury may also lead to electrolyte imbalances.
Fluid Imbalances
Fluid imbalances are of two basic types: isotonic and osmolar.
Isotonic imbalances occur when water and electrolytes are lost
or gained in equal proportions, so that the osmolality of body
fluids remains constant. Osmolar imbalances involve the loss
or gain of only water, so that the osmolality of the serum is al-
tered. Thus four categories of fluid imbalances may occur:
(a) an isotonic loss of water and electrolytes, (b) an isotonic
gain of water and electrolytes, (c) a hyperosmolar loss of only
water, and (d) a hypo-osmolar gain of only water. These are re-
ferred to, respectively, as fluid volume deficit, fluid volume
excess, dehydration (hyperosmolar imbalance), and overhy-
dration (hypo-osmolar imbalance).
Fluid Volume Deficit
Isotonic fluid volume deficit (FVD) occurs when the body loses
both water and electrolytes from the ECF in similar proportions.
Thus, the decreased volume of fluid remains isotonic. In FVD,
fluid is initially lost from the intravascular compartment, so it
often is called hypovolemia.
FVD generally occurs as a result of (a) abnormal losses
through the skin, gastrointestinal tract, or kidney; (b) de-
creased intake of fluid; (c) bleeding; or (d) movement of fluid
into a third space. See the section on third space syndrome
that follows.
For the risk factors and clinical signs related to fluid volume
deficit, see Table 524.
THIRD SPACE SYNDROME. In third space syndrome, fluid
shifts from the vascular space into an area where it is not readily
accessible as extracellular fluid. This fluid remains in the body
but is essentially unavailable for use, causing an isotonic fluid
volume deficit. Fluid may be sequestered in the bowel, in the in-
terstitial space as edema, in inflamed tissue, or in potential
spaces such as the peritoneal or pleural cavities.
The client with third space syndrome has an isotonic fluid
deficit but may not manifest apparent fluid loss or weight loss.
Careful nursing assessment is vital to effectively identify and in-
tervene for clients experiencing third-spacing. Because the fluid
shifts back into the vascular compartment after time, assessment
for manifestations of fluid volume excess or hypervolemia is
also vital.
Fluid Volume Excess
Fluid volume excess (FVE) occurs when the body retains both
water and sodiumin similar proportions to normal ECF. This is
commonly referred to as hypervolemia (increased blood vol-
ume). FVE is always secondary to an increase in the total body
sodium content, which leads to an increase in total body water.
Because both water and sodiumare retained, the serumsodium
concentration remains essentially normal and the excess vol-
ume of fluid is isotonic. Specific causes of FVE include (a) ex-
cessive intake of sodium chloride; (b) administering
sodium-containing infusions too rapidly, particularly to clients
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with impaired regulatory mechanisms; and (c) disease
processes that alter regulatory mechanisms, such as heart fail-
ure, renal failure, cirrhosis of the liver, and Cushings syndrome.
The risk factors and clinical manifestations for FVE are sum-
marized in Table 525.
EDEMA. In fluid volume excess, both intravascular and intersti-
tial spaces have an increased water and sodium content. Excess
interstitial fluid is known as edema. Edema typically is most ap-
parent in areas where the tissue pressure is low, such as around
the eyes, and in dependent tissues (known as dependent edema),
where hydrostatic capillary pressure is high.
Edema can be caused by several different mechanisms. The
three main mechanisms are increased capillary hydrostatic pres-
sure, decreased plasma oncotic pressure, and increased capil-
lary permeability. It may be due to FVE that increases capillary
hydrostatic pressures, pushing fluid into the interstitial tissues.
This type of edema is often seen in dependent tissues such as the
feet, ankles, and sacrum because of the effects of gravity. Low
levels of plasma proteins from malnutrition or liver or kidney
diseases can reduce the plasma oncotic pressure so that fluid is
not drawn into the capillaries from interstitial tissues, causing
edema. With tissue trauma and some disorders such as allergic
reactions, capillaries become more permeable, allowing fluid to
escape into interstitial tissues. Obstructed lymph flow impairs
the movement of fluid from interstitial tissues back into the vas-
cular compartment, resulting in edema.
Pitting edema is edema that leaves a small depression or pit
after finger pressure is applied to the swollen area. The pit is
caused by movement of fluid to adjacent tissue, away from the
point of pressure (Figure 52-11 ). Within 10 to 30 seconds the
pit normally disappears.
TABLE 524 Isotonic Fluid Volume Deficit
RISK FACTORS CLINICAL MANIFESTATIONS NURSING INTERVENTIONS
Loss of water and electrolytes from
Vomiting
Diarrhea
Excessive sweating
Polyuria
Fever
Nasogastric suction
Abnormal drainage or wound losses
Insufficient intake due to
Anorexia
Nausea
Inability to access fluids
Impaired swallowing
Confusion, depression
Complaints of weakness and thirst
Weight loss
2% loss mild FVD
5% loss moderate
8% loss severe
Fluid intake less than output
Decreased tissue turgor
Dry mucous membranes, sunken eyeballs,
decreased tearing
Subnormal temperature
Weak, rapid pulse
Decreased blood pressure
Postural (orthostatic) hypotension (significant
drop in BP when moving from lying to sitting
or standing position)
Flat neck veins; decreased capillary refill
Decreased central venous pressure
Decreased urine volume (<30 mL/h)
Increased specific gravity of urine (>1.030)
Increased hematocrit
Increased blood urea nitrogen (BUN)
Assess for clinical manifestations of FVD.
Monitor weight and vital signs, including
temperature.
Assess tissue turgor.
Monitor fluid intake and output.
Monitor laboratory findings.
Administer oral and intravenous fluids as
indicated.
Provide frequent mouth care.
Implement measures to prevent skin
breakdown.
Provide for safety, e.g., provide assistance for
a client rising from bed.
TABLE 525 Isotonic Fluid Volume Excess
Weight gain
2% gain mild FVE
5% gain moderate
8% gain severe
Fluid intake greater than output
Full, bounding pulse; tachycardia
Increased blood pressure and central venous
pressure
Distended neck and peripheral veins; slow
vein emptying
Moist crackles (rales) in lungs; dyspnea,
shortness of breath
Mental confusion
Excess intake of sodium-containing
intravenous fluids
Excess ingestion of sodium in diet or
medications (e.g., sodium bicarbonate
antacids such as Alka-Seltzer or hypertonic
enema solutions such as Fleets)
Impaired fluid balance regulation related
to
Heart failure
Renal failure
Cirrhosis of the liver
Assess for clinical manifestations of FVE.
Monitor weight and vital signs.
Assess for edema.
Assess breath sounds.
Monitor laboratory findings.
Place in Fowlers position.
Administer diuretics as ordered.
Restrict fluid intake as indicated.
Restrict dietary sodium as ordered.
Implement measures to prevent skin
breakdown.
koz74686_ch52.qxd 11/8/06 2:06 PM Page 1436
Dehydration
Dehydration, or hyperosmolar imbalance, occurs when water is
lost from the body leaving the client with excess sodium. Be-
cause water is lost while electrolytes, particularly sodium, are
retained, the serum osmolality and serum sodium levels in-
crease. Water is drawn into the vascular compartment from the
interstitial space and cells, resulting in cellular dehydration.
Older adults are at particular risk for dehydration because of de-
creased thirst sensation. This type of water deficit also can af-
fect clients who are hyperventilating or have prolonged fever or
are in diabetic ketoacidosis and those receiving enteral feedings
with insufficient water intake.
Overhydration
Overhydration, also known as hypo-osmolar imbalance or water
excess, occurs when water is gained in excess of electrolytes, re-
sulting in low serum osmolality and low serum sodium levels.
Water is drawn into the cells, causing themto swell. In the brain
this can lead to cerebral edema and impaired neurologic func-
tion. Water intoxication often occurs when both fluid and elec-
trolytes are lost, for example, through excessive sweating, but
only water is replaced. It can also result from the syndrome of
inappropriate antidiuretic hormone (SIADH), a disorder that can
occur with some malignant tumors, AIDS, head injury, or ad-
ministration of certain drugs such as barbiturates or anesthetics.
Figure 52-11 Evaluation of edema. A, Palpate for edema over the tibia as shown here and behind the medial malleolus, and over the dorsum of
each foot. B, Four-point scale for grading edema.
2mm
1+ Barely detectable
4mm
2+ 2 to 4 mm
6mm
3+ 5 to 7 mm
12mm
4+ More than 7 mm
B A
DRUG CAPSULE Diuretic Agent furosemide (Lasix)
THE CLIENT WITH FLUID VOLUME EXCESS
Furosemide inhibits sodium and chloride reabsorption in the loop of Henle and the distal renal tubule. This results in significant diuresis,
with renal excretion of water, sodium chloride, magnesium, hydrogen, and calcium.
Furosemide is commonly used for the clinical management of edema secondary to heart failure, treatment of hypertension, and treat-
ment of hepatic or renal disease. Therapeutic effects include diuresis and lowering of blood pressure.
NURSING RESPONSIBILITIES
Assess the clients fluid status regularly. Assessment should in-
clude daily weights, close monitoring of intake and output, skin
turgor, edema, lung sounds, and mucous membranes.
Monitor the clients potassium levels. Furosemide is a loop
diuretic which excretes potassium and may result in
hypokalemia.
Administer in the morning to avoid increased urination during
hours of sleep.
If the client is also taking digitalis glycosides, he or she should be
assessed for anorexia, nausea, vomiting, muscle cramps, pares-
thesia, and confusion. The potassium-depleting effect of
furosemide places the client at increased risk for digitalis toxicity.
CLIENT AND FAMILY TEACHING
Medication should be taken exactly as directed. If you miss a
dose, take it as soon as possible; however, if a day has been
missed, do not double the dose the next day.
Weigh on a daily basis and report weight gain or loss of more
than 3 lb in 1 day to your primary care provider.
Contact your primary care provider immediately if you begin to
experience muscle weakness, cramps, nausea, dizziness,
numbness, or tingling of the extremities.
Some form of potassium supplementation will be needed. The
primary care provider may order oral potassium supplements for
you; if not, you will need to consume a diet high in potassium.
Make position changes slowly in order to minimize dizziness
from orthostatic hypotension.
Note: Prior to administering any medication, review all aspects with a current drug handbook or other reliable source.
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Electrolyte Imbalances
The most common and most significant electrolyte imbalances
involve sodium, potassium, calcium, magnesium, chloride, and
phosphate.
Sodium
Sodium (Na
), the most abundant cation in the extracellular

fluid, not only moves into and out of the body but also moves in
careful balance among the three fluid compartments. It is found
in most body secretions, for example, saliva, gastric and intes-
tinal secretions, bile, and pancreatic fluid. Therefore, continu-
ous excretion of any of these fluids, such as via intestinal
suction, can result in a sodium deficit. Because of its role in reg-
ulating water balance, sodium imbalances usually are accompa-
nied by water imbalance.
Hyponatremia is a sodium deficit, or serum sodium level of
less than 135 mEq/L, and is, in acute care settings, a common
electrolyte imbalance. Because of sodiums role in determining
the osmolality of ECF, hyponatremia typically results in a low
serum osmolality. Water is drawn out of the vascular compart-
ment into interstitial tissues and the cells (Figure 52-12 , A),
causing the clinical manifestations associated with this disorder.
As sodium levels decrease, the brain and nervous system are af-
fected by cellular edema. Severe hyponatremia, serum levels
below 110 mEq/L, is a medical emergency and can lead to per-
manent neurological damage (Astle, 2005).
Hypernatremia is excess sodium in ECF, or a serum sodium
of greater than 145 mEq/L. Because the osmotic pressure of ex-
tracellular fluid is increased, fluid moves out of the cells into the
ECF (Figure 52-12 , B). As a result, the cells become dehy-
drated. Like hyponatremia, the primary manifestations of hy-
pernatremia are neurological in nature.
It is important to note that a persons thirst mechanism pro-
tects against hypernatremia. For example, when an individual
becomes thirsty, the body is stimulated to drink water which
helps correct the hypernatremia. Clients at risk for hyperna-
tremia are those who are unable to access water (e.g., uncon-
scious, unable to request fluids such as infants or elders with
dementia, or ill clients with an impaired thirst mechanism).
Table 526 lists risk factors and clinical signs for hypona-
tremia and hypernatremia.
Potassium
Although the amount of potassium (K
) in extracellular fluid is
small, it is vital to normal neuromuscular and cardiac function.
Normal renal function is important for maintenance of potas-
sium balance as 80% of potassium is excreted by the kidneys.
Potassium must be replaced daily to maintain its balance. Nor-
mally, potassium is replaced in food. See previous Box 521 on
page 1431 for a review of foods high in potassium.
Hypokalemia is a potassium deficit or a serum potassium
level of less than 3.5 mEq/L. Gastrointestinal losses of potas-
sium through vomiting and gastric suction are common causes
of hypokalemia, as are the use of potassium-wasting diuretics,
such as thiazide diuretics or loop diuretics (e.g., furosemide).
Symptoms of hypokalemia are usually mild until the level drops
below 3 mEq/L unless the decrease in potassium was rapid.
When the decrease is gradual, the body compensates by shifting
potassium from the intracellular environment into the serum.
Hyperkalemia is a potassium excess or a serum potassium
level greater than 5.0 mEq/L. Hyperkalemia is less common
than hypokalemia and rarely occurs in clients with normal renal
function. It is, however, more dangerous than hypokalemia and
can lead to cardiac arrest. As with hypokalemia, symptoms are
more severe and occur at lower levels when the increase in
potassium is abrupt. Table 526 lists risk factors and clinical
signs for hypokalemia and hyperkalemia.
RESEARCH NOTE How Prevalent Is Chronic Dehydration in Elders?
Previous research has documented that dehydration is a problem in
hospitalized elders, and low fluid intake has been documented to be a
problem in nursing home residents. The authors questioned whether
chronic dehydration is also a problem in elders living in the community.
The researchers conducted a descriptive, retrospective study of 185 eld-
ers ranging from 75 to 100 years old. This group of elders visited a hos-
pital emergency department during a 1-month period of time.
Dehydration was defined as a ratio of blood urea nitrogen to creatine
(BUN:Cr) greater than 20:1. Forty-eight percent of the group were de-
hydrated on admission to the emergency department. The elders from
a residential facility were most likely to be dehydrated (65%); however,
44% of the elders living in the community were dehydrated.
IMPLICATIONS
The results demonstrated that dehydration is a problem with both eld-
ers living in the community as well as elders living in residential facili-
ties. Prevention of dehydration is an important intervention for nurses
working with elders. Nursing interventions need to include talking with
elders and their families about the dangers of dehydration and sug-
gesting strategies to prevent dehydration.
Note: From Unrecognized Chronic Dehydration in Older Adults. Examining Preva-
lence Rate and Risk Factors, by J. A. Bennett, V. Thomas, and B. Riegel, 2004,
Journal of Gerontological Nursing, 30(1), pp. 2228. Copyright 2004 SLACK,
Inc. Reprinted with permission.
H
2
O
H
2
O
H
2
O
Cell swells as water
is pulled in from ECF
Hyponatremia:
Na
+
less than 135 mEq/L
A
Figure 52-12 The extracellular sodium level affects cell size. A, In
hyponatremia, cells swell; B, in hypernatremia, cells shrink in size.
H
2
O
Cell shrinks as water
is pulled out into ECF
Hypernatremia:
Na
+
greater than 145 mEq/L
B
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1438
TABLE 526 Electrolyte Imbalances
Hyponatremia
Loss of sodium
Gastrointestinal fluid loss
Sweating
Use of diuretics
Gain of water
Hypotonic tube feedings
Excessive drinking of water
Excess IV D5W (dextrose in water)
administration
Syndrome of inappropriate ADH
(SIADH)
Head injury
AIDS
Malignant tumors
Hypernatremia
Loss of water
Insensible water loss (hyperventilation
or fever)
Diarrhea
Water deprivation
Gain of sodium
Parenteral administration of saline
solutions
Hypertonic tube feedings without
adequate water
Excessive use of table salt (1 tsp
contains 2,300 mg of sodium)
Conditions such as
Diabetes insipidus
Heat stroke
Hypokalemia
Loss of potassium
Vomiting and gastric suction
Diarrhea
Heavy perspiration
Use of potassium-wasting drugs (e.g.,
diuretics)
Poor intake of potassium (as with
debilitated clients, alcoholics, anorexia
nervosa)
Hyperaldosteronism
Hyperkalemia
Decreased potassium excretion
Renal failure
Hypoaldosteronism
Potassium-conserving diuretics
High potassium intake
Lethargy, confusion, apprehension
Muscle twitching
Abdominal cramps
Anorexia, nausea, vomiting
Headache
Seizures, coma
Laboratory findings:
Serum sodium below 135 mEq/L
Serum osmolality below 280 mOsm/kg
Thirst
Dry, sticky mucous membranes
Tongue red, dry, swollen
Weakness
Severe hypernatremia:
Fatigue, restlessness
Decreasing level of consciousness
Disorientation
Convulsions
Serum sodium above 145 mEq/L
Serum osmolality above 300 mOsm/kg
Muscle weakness, leg cramps
Fatigue, lethargy
Decreased bowel sounds, decreased bowel
motility
Cardiac dysrhythmias
Depressed deep-tendon reflexes
Weak, irregular pulses
Serum potassium below 3.5 mEq/L
Arterial blood gases (ABGs) may show alkalosis
T wave flattening and ST segment depression
on ECG
Gastrointestinal hyperactivity, diarrhea
Irritability, apathy, confusion
Cardiac dysrhythmias or arrest
Muscle weakness, areflexia (absence of
reflexes)
Decreased heart rate;
Irregular pulse
Assess clinical manifestations.
Monitor laboratory data (e.g., serum sodium).
Assess client closely if administering
hypertonic saline solutions.
Encourage food and fluid high in sodium if
permitted (e.g., table salt, bacon, ham,
processed cheese).
Limit water intake as indicated.
Monitor behavior changes (e.g., restlessness,
disorientation).
Monitor laboratory findings (e.g., serum
sodium).
Encourage fluids as ordered.
Monitor diet as ordered (e.g., restrict intake of
salt and foods high in sodium).
Monitor heart rate and rhythm.
Monitor clients receiving digitalis (e.g., digoxin)
closely, because hypokalemia increases risk of
digitalis toxicity.
Administer oral potassium as ordered with
food or fluid to prevent gastric irritation.
Administer IV potassium solutions at a rate no
faster than 1020 mEq/h; never administer
undiluted potassium intravenously. For clients
receiving IV potassium, monitor for pain and
inflammation at the injection site.
Teach client about potassium-rich foods.
Teach clients how to prevent excessive loss of
potassium (e.g., through abuse of diuretics
and laxatives).
Closely monitor cardiac status and ECG.
Administer diuretics and other medications
such as glucose and insulin as ordered.
Hold potassium supplements and K
conserving diuretics.
continued on page 1440
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1439
Hyperkalemiacontinued
TABLE 526 Electrolyte Imbalancescontinued
Excessive use of K
containing salt
substitutes
Excessive or rapid IV infusion of
potassium
Potassium shift out of the tissue cells
into the plasma (e.g., infections, burns,
acidosis)
Hypocalcemia
Surgical removal of the parathyroid
glands
Conditions such as
Hypoparathyroidism
Acute pancreatitis
Hyperphosphatemia
Thyroid carcinoma
Inadequate vitamin D intake
Malabsorption
Hypomagnesemia
Alkalosis
Sepsis
Alcohol abuse
Hypercalcemia
Prolonged immobilization
Conditions such as
Hyperparathyroidism
Malignancy of the bone
Pagets disease
Hypomagnesemia
Excessive loss from the gastrointestinal
tract (e.g., from nasogastric suction,
diarrhea, fistula drainage)
Long-term use of certain drugs (e.g.,
diuretics, aminoglycoside antibiotics)
Conditions such as
Chronic alcoholism
Pancreatitis
Burns
Paresthesias and numbness in extremities
Serum potassium above 5.0 mEq/L
Peaked T wave, widened QRS on ECG
Numbness, tingling of the extremities and
around the mouth
Muscle tremors, cramps; if severe can progress
to tetany and convulsions
Cardiac dysrhythmias; decreased cardiac output
Positive Trousseaus and Chvosteks signs (see
Table 528)
Confusion, anxiety, possible psychoses
Hyperactive deep tendon reflexes
Serum calcium less than 8.5 mg/dL or
4.5 mEq/L (total)
Lengthened QT intervals
Prolonged ST segments
Lethargy, weakness
Bone pain
Constipation
Polyuria, hypercalciuria
Flank pain secondary to urinary calculi
Dysrhythmias, possible heart block
Serum calcium greater than 10.5 mg/dL or
5.5 mEq/L (total)
Shortened QT intervals
Shortened ST segments
Neuromuscular irritability with tremors
Increased reflexes, tremors, convulsions
Positive Chvosteks and Trousseaus signs (see
Table 528)
Tachycardia, elevated blood pressure,
dysrhythmias
Disorientation and confusion
Vertigo
Anorexia, dysphagia
Respiratory difficulties
Serum magnesium below 1.5 mEq/L
Prolonged PR intervals, widened QRS
complexes, prolonged QT intervals, depressed
ST segments, broad flattened T waves,
prominent U waves
Monitor serum K
levels carefully; a rapid drop

may occur as potassium shifts into the cells.
Teach clients to avoid foods high in potassium
and salt substitutes.
Closely monitor respiratory and cardiovascular
status.
Take precautions to protect a confused client.
Administer oral or parenteral calcium
supplements as ordered. When administering
intravenously, closely monitor cardiac status
and ECG during infusion.
Teach clients at high risk for osteoporosis about
Dietary sources rich in calcium.
Recommendation for 1,0001,500 mg of
calcium per day.
Calcium supplements.
Regular exercise.
Estrogen replacement therapy for
postmenopausal women.
Increase client movement and exercise.
Encourage oral fluids as permitted to maintain
a dilute urine.
Teach clients to limit intake of food and fluid
high in calcium.
Encourage ingestion of fiber to prevent
constipation.
Protect a confused client; monitor for
pathologic fractures in clients with long-term
hypercalcemia.
Encourage intake of acid-ash fluids (e.g.,
prune or cranberry juice) to counteract
deposits of calcium salts in the urine.
Assess clients receiving digitalis for digitalis
toxicity.
Hypomagnesemia increases the risk of toxicity.
Take protective measures when there is a
possibility of seizures.
Assess the clients ability to swallow water
prior to initiating oral feeding.
Initiate safety measures to prevent injury
during seizure activity.
Carefully administer magnesium salts as
ordered.
Encourage clients to eat magnesium-rich
foods if permitted (e.g., whole grains, meat,
seafood, and green leafy vegetables).
Refer clients to alcohol treatment programs as
indicated.
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1440
TABLE 526 Electrolyte Imbalancescontinued
Hypermagnesemia
Abnormal retention of magnesium, as in
Renal failure
Adrenal insufficiency
Treatment with magnesium salts
Peripheral vasodilation, flushing
Nausea, vomiting
Muscle weakness, paralysis
Hypotension, bradycardia
Lethargy, drowsiness
Respiratory depression, coma
Respiratory and cardiac arrest if
hypermagnesemia is severe
Serum magnesium above 2.5 mEq/L
Electrocardiogram showing prolonged QT
interval, prolonged PR interval, widened QRS
complexes, tall T waves
Monitor vital signs and level of consciousness
when clients are at risk.
If patellar reflexes are absent, notify the
primary care provider.
Advise clients who have renal disease to
contact their primary care provider before
taking over-the-counter drugs.
CLINICAL ALERT
Potassium may be given intravenously for severe hypokalemia. It must
ALWAYS be diluted appropriately and NEVER be given IV push. Potassium
that is to be given IV should be mixed in the pharmacy and double-
checked prior to administration by two nurses. The usual concentration of
IV potassium is 20 to 40 mEq/L.
Calcium
Regulating levels of calcium (Ca
2
) in the body is more com-
plex than the other major electrolytes so calcium balance can be
affected by many factors. Imbalances of this electrolyte are rel-
atively common.
Hypocalcemia is a calcium deficit, or a total serum calcium
level of less than 8.5 mg/dL or an ionized calcium level of less
than 4.0 mg/dL. Severe depletion of calcium can cause tetany
with muscle spasms and paresthesias (numbness and tingling
around the mouth and hands and feet) and can lead to convul-
sions. Two signs indicate hypocalcemia: The Chvosteks sign is
contraction of the facial muscles that is produced by tapping the
facial nerve in front of the ear (Figure 52-13 , A). Trousseaus
sign is a carpal spasm that occurs by inflating a blood pressure
cuff on the upper arm to 20 mm Hg greater than the systolic
pressure for 2 to 5 minutes (Figure 52-13 , B). Clients at great-
est risk for hypocalcemia are those whose parathyroid glands
have been removed. This is frequently associated with total thy-
roidectomy or bilateral neck surgery for cancer. Low serum
magnesium levels (hypomagnesemia) and chronic alcoholism
also increase the risk of hypocalcemia.
Hypercalcemia, or total serum calcium levels greater than
10.5 mg/dL, or an ionized calcium level of greater than 5.0
mg/dL, most often occurs when calcium is mobilized from the
bony skeleton. This may be due to malignancy or prolonged im-
mobilization.
B. Positive Trousseau's Sign
A. Positive Chvostek's Sign
Figure 52-13 A, Positive Chvosteks sign. B, Positive Trousseaus sign.
From Lemone, Priscilla; Burke, Karen M., Medical Surgical Nursing: Critical Thinking in Client Care, 3rd ed 2004. Reproduced with permission of Pearson Education, Inc., Upper
Saddle River, New Jersey.
koz74686_ch52.qxd 11/13/06 4:49 PM Page 1441
The risk factors and clinical manifestations related to cal-
cium imbalances are found in Table 526.
Magnesium
Magnesium (Mg
2
) imbalances are relatively common in
hospitalized clients, although they may be unrecognized.
Hypomagnesemia is a magnesium deficiency, or a total serum
magnesium level of less than 1.5 mEq/L. It occurs more fre-
quently than hypermagnesemia. Chronic alcoholism is the most
common cause of hypomagnesemia. Magnesium deficiency also
may aggravate the manifestations of alcohol withdrawal, such as
delirium tremens (DTs). Hypermagnesemia is present when the
serum magnesium level rises above 2.5 mEq/L. It is due to in-
creased intake or decreased excretion. It is often iatrogenic, that
is, a result of overzealous magnesium therapy.
Table 526 lists risk factors and manifestations for clients
with altered magesium balance.
Chloride
Because of the relationship between sodium ions and chloride
ions (Cl
), imbalances of chloride commonly occur in conjunc-

tion with sodium imbalances. Hypochloremia is a decreased
serum chloride level, in adults a level below 95 mEq/L, and is
usually related to excess losses of chloride ion through the GI
tract, kidneys, or sweating. Hypochloremic clients are at risk
for alkalosis and may experience muscle twitching, tremors, or
tetany.
Conditions that cause sodium retention also can lead to a high
serum chloride level or hyperchloremia, in adults a level above
108 mEq/L. Excess replacement of sodium chloride or potassium
chloride are additional risk factors for high serum chloride levels.
The manifestations of hyperchloremia include acidosis, weak-
ness, and lethargy, with a risk of dysrhythmias and coma.
Phosphate
The phosphate anion PO
4
is found in both intracellular and ex-

tracellular fluid. Most of the phosphorus (P
) in the body exists

as PO
4
. Phosphate is critical for cellular metabolism because it

is a major component of adenosine triphosphate (ATP).
Phosphate imbalances frequently are related to therapeutic in-
terventions for other disorders. Glucose and insulin administra-
tion and total parenteral nutrition can cause phosphate to shift
into the cells from extracellular fluid compartments, leading to
hypophosphatemia, defined in adults as a total serum phosphate
level less than 2.5 mg/dL. Alcohol withdrawal, acidbase imbal-
ances, and the use of antacids that bind with phosphate in the GI
tract are other possible causes of low serum phosphate levels.
Manifestations of hypophosphatemia include paresthesias, mus-
cle weakness and pain, mental changes, and possible seizures.
Hyperphosphatemia, defined in adults as a total serum phos-
phate level greater than 4.5 mg/dL, occurs when phosphate shifts
out of the cells into extracellular fluids (e.g., due to tissue trauma
or chemotherapy for malignant tumors), in renal failure, or when
excess phosphate is administered or ingested. Infants who are fed
cows milk are at risk for hyperphosphatemia, as are people using
phosphate-containing enemas or laxatives. Clients who have high
serum phosphate levels may experience numbness and tingling
around the mouth and in the fingertips, muscle spasms, and tetany.
AcidBase Imbalances
Acidbase imbalances generally are classified as respiratory or
metabolic by the general or underlying cause of the disorder. Car-
bonic acid levels are normally regulated by the lungs through the
retention or excretion of carbon dioxide, and problems of regula-
tion lead to respiratory acidosis or alkalosis. Bicarbonate and hy-
drogen ion levels are regulated by the kidneys, and problems of
regulation lead to metabolic acidosis or alkalosis. Healthy regula-
tory systems will attempt to correct acidbase imbalances, a
process called compensation.
Respiratory Acidosis
Hypoventilation and carbon dioxide retention cause carbonic acid
levels to increase and the pH to fall below 7.35, a condition
known as respiratory acidosis. Serious lung diseases such as
asthma and COPD are common causes of respiratory acidosis.
Central nervous system depression due to anesthesia or a narcotic
overdose can sufficiently slow the respiratory rate so that carbon
dioxide is retained. When respiratory acidosis occurs, the kidneys
retain bicarbonate to restore the normal carbonic acid to bicarbon-
ate ratio. Recall, however, that the kidneys are relatively slow to
respond to changes in acidbase balance, so this compensatory
response may require hours to days to restore the normal pH.
Respiratory Alkalosis
When a person hyperventilates, more carbon dioxide than nor-
mal is exhaled, carbonic acid levels fall, and the pH rises to
greater than 7.45. This condition is termed respiratory alkalosis.
Psychogenic or anxiety-related hyperventilation is a common
cause of respiratory alkalosis. Other causes include fever and
respiratory infections. In respiratory alkalosis, the kidneys will
excrete bicarbonate to return the pH to within the normal range.
Often, however, the cause of the hyperventilation is eliminated
and the pH returns to normal before renal compensation occurs.
Metabolic Acidosis
When bicarbonate levels are low in relation to the amount of
carbonic acid in the body, the pH falls and metabolic acidosis
develops. This may develop because of renal failure and the in-
ability of the kidneys to excrete hydrogen ion and produce bi-
carbonate. It also may occur when too much acid is produced in
the body, for example, in diabetic ketoacidosis or starvation
when fat tissue is broken down for energy. Metabolic acidosis
stimulates the respiratory center, and the rate and depth of res-
pirations increase. Carbon dioxide is eliminated and carbonic
acid levels fall, minimizing the change in pH. This respiratory
compensation occurs within minutes of the pH imbalance.
Metabolic Alkalosis
In metabolic alkalosis, the amount of bicarbonate in the body
exceeds the normal 20-to-1 ratio. Ingestion of bicarbonate of
soda as an antacid is one cause of metabolic alkalosis. Another
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1442
ANATOMY & PHYSIOLOGY REVIEW Gas Exchange
QUESTIONS
1. Hypoventilation can affect gas exchange. What are some causes of hypoventilation?
2. How does the shallow breathing from hypoventilation cause the PaCO
2
to increase and the pH to decrease?
3. ABGs that indicate an increased PaCO
2
and a decreased pH reflect which acidbase imbalance?
4. Hyperventilation can also affect gas exchange. What are some causes of hyperventilation?
5. How does hyperventilation cause a decreased PaCO
2
and increased pH?
6. ABGs that indicate a decreased PaCO
2
and an increased pH reflect which acidbase imbalance?
cause is prolonged vomiting with loss of hydrochloric acid from
the stomach. The respiratory center is depressed in metabolic al-
kalosis, and respirations slow and become more shallow. Car-
bon dioxide is retained and carbonic acid levels increase,
helping balance the excess bicarbonate.
The risk factors and manifestations for acidbase imbalances
are listed in Table 527.
NURSING MANAGEMENT
Assessing
Assessing clients for fluid, electrolyte, and acidbase balance
and imbalances is an important nursing care function. Compo-
nents of the assessment include (a) the nursing history, (b) phys-
ical assessment of the client, (c) clinical measurements, and
(d) review of laboratory test results.
Nursing History
The nursing history is particularly important for identifying
clients who are at risk for fluid, electrolyte, and acidbase im-
balances. The current and past medical history reveal conditions
such as chronic lung disease or diabetes mellitus that can disrupt
normal balances. Medications prescribed to treat acute or
chronic conditions (e.g., diuretic therapy for hypertension) also
may place the client at risk for altered homeostasis. Functional,
developmental, and socioeconomic factors must also be consid-
ered in assessing the clients risk. Older people and very young
children, clients who must depend on others to meet their needs
for food and fluid intake, and people who cannot afford or do
not have the means to cook food for a balanced diet (e.g., home-
less people) are at greater risk for fluid and electrolyte imbal-
ances. Common risk factors are listed in Box 523.
When obtaining the nursing history, the nurse needs to not
only recognize risk factors but also elicit data about the clients
Bronchiole
Pulmonary
vein
Pulmonary
artery branch
Red blood cell
O
2
molecule
CO
2
molecule
Blood
Capillary wall
Alveolar wall
O
2
O
2
CO
2
CO
2
From Turley, Susan M., Medical Language, 1st ed., 2002.
Reproduced with permission of Pearson Education, Inc.,
Upper Saddle River, New Jersey.
koz74686_ch52.qxd 11/13/06 4:49 PM Page 1443
TABLE 527 AcidBase Imbalances
Respiratory Acidosis
Increased pulse and respiratory rates
Headache, dizziness
Confusion, decreased level of consciousness
(LOC)
Convulsions
Warm, flushed skin
Chronic:
Weakness
Headache
Arterial blood pH less than 7.35
PaCO
2
above 45 mm Hg
HCO
3
normal or slightly elevated in acute;

above 26 mEq/L in chronic
Complaints of shortness of breath, chest
tightness
Light-headedness with circumoral paresthesias
and numbness and tingling of the extremities
Difficulty concentrating
Tremulousness, blurred vision
Laboratory findings (in uncompensated
respiratory alkalosis):
Arterial blood pH above 7.45
PaCO
2
less than 35 mm Hg
Kussmauls respirations (deep, rapid
respirations)
Lethargy, confusion
Headache
Weakness
Nausea and vomiting
Arterial blood pH below 7.35
Serum bicarbonate less than 22 mEq/L
PaCO
2
less than 38 mm Hg with respiratory
compensation
Decreased respiratory rate and depth
Dizziness
Circumoral paresthesias, numbness and
tingling of the extremities
Hypertonic muscles, tetany
Arterial blood pH above 7.45
Serum bicarbonate greater than 26 mEq/L
PaCO
2
higher than 45 mm Hg with respiratory
compensation
Acute lung conditions that impair
alveolar gas exchange (e.g., pneumonia,
acute pulmonary edema, aspiration of
foreign body, near-drowning)
Chronic lung disease (e.g., asthma,
cystic fibrosis, or emphysema)
Overdose of narcotics or sedatives that
depress respiratory rate and depth
Brain injury that affects the respiratory
center
Airway obstruction
Mechanical chest injury
Respiratory Alkalosis
Hyperventilation due to
Extreme anxiety
Elevated body temperature
Overventilation with a mechanical
ventilator
Hypoxia
Salicylate overdose
Brain stem injury
Fever
Increased basal metabolic rate
Metabolic Acidosis
Conditions that increase nonvolatile
acids in the blood (e.g., renal
impairment, diabetes mellitus,
starvation)
Conditions that decrease bicarbonate
(e.g., prolonged diarrhea)
Excessive infusion of chloride-containing
IV fluids (e.g., NaCl)
Excessive ingestion of acids such as
salicylates
Cardiac arrest
Metabolic Alkalosis
Excessive acid losses due to
Vomiting
Gastric suction
Excessive use of potassium-losing
diuretics
Excessive adrenal corticoid hormones
due to
Cushings syndrome
Hyperaldosteronism
Excessive bicarbonate intake from
Antacids
Parenteral NaHCO
3
Frequently assess respiratory status and lung
sounds.
Monitor airway and ventilation; insert artificial
airway and prepare for mechanical ventilation
as necessary.
Administer pulmonary therapy measures such
as inhalation therapy, percussion and postural
drainage, bronchodilators, and antibiotics as
ordered.
Monitor fluid intake and output, vital signs, and
arterial blood gases.
Administer narcotic antagonists as indicated.
Maintain adequate hydration (23 L of fluid
per day).
Monitor vital signs and ABGs.
Assist client to breathe more slowly.
Help client breathe in a paper bag or apply a
rebreather mask (to inhale CO
2
).
Monitor ABG values, intake and output, and
LOC.
Administer IV sodium bicarbonate carefully if
ordered.
Treat underlying problem as ordered.
Monitor intake and output closely.
Monitor vital signs, especially respirations, and
LOC.
Administer ordered IV fluids carefully.
Treat underlying problem.
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1444
food and fluid intake, fluid output, and the presence of signs or
symptoms suggestive of altered fluid and electrolyte balance.
The Assessment Interview provides examples of questions to
elicit information regarding fluid, electrolyte, and acidbase
balance.
Physical Assessment
Physical assessment to evaluate a clients fluid, electrolyte,
and acidbase status focuses on the skin, the oral cavity and
mucous membranes, the eyes, the cardiovascular and respira-
tory systems, and neurologic and muscular status. Data from
this physical assessment are used to expand and verify infor-
mation obtained in the nursing history. The focused physical
assessment is summarized in Table 528 on page 1446. Refer
to Tables 525 through 528 for possible abnormal findings
related to specific imbalances.
Clinical Measurements
Three simple clinical measurements that the nurse can initiate
without a primary care providers order are daily weights, vital
signs, and fluid intake and output.
DAILY WEIGHTS. Daily weight measurements provide a rela-
tively accurate assessment of a clients fluid status. Significant
changes in weight over a short time (e.g., more than 5 pounds
BOX 523 Common Risk Factors for Fluid, Electrolyte, and AcidBase Imbalances
CHRONIC DISEASES AND CONDITIONS
Chronic lung disease (COPD, asthma, cystic fibrosis)
Heart failure
Kidney disease
Diabetes mellitus
Cushings syndrome or Addisons disease
Cancer
Malnutrition, anorexia nervosa, bulimia
Ileostomy
ACUTE CONDITIONS
Acute gastroenteritis
Bowel obstruction
Head injury or decreased level of consciousness
Trauma such as burns or crushing injuries
Surgery
Fever, draining wounds, fistulas
MEDICATIONS
Diuretics
Corticosteroids
Nonsteroidal anti-inflammatory drugs
TREATMENTS
Chemotherapy
IV therapy and total parenteral nutrition
Nasogastric suction
Enteral feedings
Mechanical ventilation
OTHER FACTORS
Age: Very old or very young
Inability to access food and fluids independently
ASSESSMENT INTERVIEW Fluid, Electrolyte, and AcidBase Balance
CURRENT AND PAST MEDICAL HISTORY
Are you currently seeing a health care provider for treatment of any
chronic diseases such as kidney disease, heart disease, high blood
pressure, diabetes insipidus, or thyroid or parathyroid disorders?
Have you recently experienced any acute conditions such as gas-
troenteritis, severe trauma, head injury, or surgery? If so, describe
them.
MEDICATIONS AND TREATMENTS
Are you currently taking any medications on a regular basis such
as diuretics, steroids, potassium supplements, calcium supple-
ments, hormones, salt substitutes, or antacids?
Have you recently undergone any treatments such as dialysis, par-
enteral nutrition, or tube feedings or been on a ventilator? If so,
when and why?
FOOD AND FLUID INTAKE
How much and what type of fluids do you drink each day?
Describe your diet for a typical day. (Pay particular attention to the
clients intake of foods high in sodium content, of protein, and of
whole grains, fruits, and vegetables.)
Have there been any recent changes in your food or fluid intake,
for example, as a result of following a weight-loss program?
Are you on any type of restricted diet?
Has your food or fluid intake recently been affected by changes in ap-
petite, nausea, or other factors such as pain or difficulty breathing?
FLUID OUTPUT
Have you noticed any recent changes in the frequency or amount
of urine output?
Have you recently experienced any problems with vomiting, diar-
rhea, or constipation? If so, when and for how long?
Have you noticed any other unusual fluid losses such as excessive
sweating?
FLUID, ELECTROLYTE, AND ACIDBASE IMBALANCES
Have you gained or lost weight in recent weeks?
Have you recently experienced any symptoms such as excessive
thirst, dry skin or mucous membranes, dark or concentrated urine,
or low urine output?
Do you have problems with swelling of your hands, feet, or ankles?
Do you ever have difficulty breathing, especially when lying down
or at night? How many pillows do you use to sleep?
Have you recently experienced any of the following symptoms: dif-
ficulty concentrating or confusion; dizziness or feeling faint; mus-
cle weakness, twitching, cramping, or spasm; excessive fatigue;
abnormal sensations such as numbness, tingling, burning, or prick-
ling; abdominal cramping or distention; heart palpitations?
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1445
in a week or less) are indicative of acute fluid changes. Each
kilogram (2.2 lb) of weight gained or lost is equivalent to 1 L
of fluid gained or lost. Such fluid gains or losses indicate
changes in total body fluid volume rather than in any specific
compartment, such as the intravascular compartment. Rapid
losses or gains of 5% to 8% of total body weight indicate mod-
erate to severe fluid volume deficits or excesses.
To obtain accurate weight measurements, the nurse should bal-
ance the scale before each use and weigh the client (a) at the same
time each day (e.g., before breakfast and after the first void),
(b) wearing the same or similar clothing, and (c) on the same scale.
The type of scale (i.e., standing, bed, chair) should be documented.
Regular assessment of weight is particularly important for
clients in the community and extended care facilities who are at
risk for fluid imbalance. For these clients, measuring intake and
output may be impractical because of lifestyle or problems with
incontinence. Regular weight measurement, either daily, every
other day, or weekly, provides valuable information about the
clients fluid volume status.
VITAL SIGNS. Changes in the vital signs may indicate, or in
some cases precede, fluid, electrolyte, and acidbase imbal-
ances. For example, elevated body temperature may be a re-
sult of dehydration or a cause of increased body fluid losses.
Tachycardia is an early sign of hypovolemia. Pulse volume
will decrease in FVD and increase in FVE. Irregular pulse
rates may occur with electrolyte imbalances. Changes in re-
spiratory rate and depth may cause respiratory acidbase im-
TABLE 528 Focused Physical Assessment for Fluid, Electrolyte, or AcidBase Imbalances
SYSTEM ASSESSMENT FOCUS TECHNIQUE POSSIBLE ABNORMAL FINDINGS
Skin
Mucous membranes
Eyes
Fontanels (infant)
Cardiovascular system
Respiratory system
Neurologic
Color, temperature, moisture
Turgor
Edema
Color, moisture
Firmness
Firmness, level
Heart rate
Peripheral pulses
Blood pressure
Capillary refill
Venous filling
Respiratory rate and pattern
Lung sounds
Level of consciousness (LOC)
Orientation, cognition
Motor function
Reflexes
Abnormal reflexes
Inspection, palpation
Gently pinch up a fold of skin over
sternum or inner aspect of thigh for
adults, on the abdomen or medial
thigh for children
Inspect for visible swelling around
eyes, in fingers, and in lower
extremities
Compress the skin over the dorsum
of the foot, around the ankles, over
the tibia, in the sacral area
Inspection
Gently palpate eyeball with lid closed
Inspect and gently palpate anterior
fontanel
Auscultation, cardiac monitor
Palpation
Auscultation of Korotkoffs sounds
BP assessment lying and standing
Palpation
Inspection of jugular veins and hand
veins
Inspection
Auscultation
Observation, stimulation
Questioning
Strength testing
Deep-tendon reflex (DTR) testing
Chvosteks sign: Tap over facial nerve
about 2 cm anterior to tragus of ear
Trousseaus sign: Inflate a blood
pressure cuff on the upper arm to
20 mm Hg greater than the systolic
pressure, leave in place for 2 to
5 minutes
Flushed, warm, very dry
Moist or diaphoretic
Cool and pale
Poor turgor: Skin remains tented for
several seconds instead of
immediately returning to normal
position
Skin around eyes is puffy, lids appear
swollen; rings are tight; shoes leave
impressions on feet
Depression remains (pitting): see
scale for describing edema in
Figure 52-11
Mucous membranes dry, dull in
appearance; tongue dry and cracked
Eyeball feels soft to palpation
Fontanel bulging, firm
Fontanel sunken, soft
Tachycardia, bradycardia; irregular;
dysrhythmias
Weak and thready; bounding
Hypotension
Postural hypotension
Slowed capillary refill
Jugular venous distention; flat jugular
veins, poor venous refill
Increased or decreased rate and
depth of respirations
Crackles or moist rales
Decreased LOC, lethargy, stupor, or
coma
Disoriented, confused; difficulty
concentrating
Weakness, decreased motor strength
Hyperactive or depressed DTRs
Facial muscle twitching including
eyelids and lips on side of stimulus
Carpal spasm: contraction of hand
and fingers on affected side
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1446
balances or act as a compensatory mechanism in metabolic
acidosis or alkalosis.
Blood pressure, a sensitive measure to detect blood volume
changes, may fall significantly with FVD and hypovolemia or
increase with FVE. Postural, or orthostatic, hypotension may
also occur with FVD and hypovolemia.
To assess for orthostatic hypotension, measure the clients
blood pressure and pulse in a supine position. Allow the client
to remain in that position for 3 to 5 minutes, leaving the blood
pressure cuff on the arm. Stand the client up and immediately
reassess the blood pressure and pulse. Adrop of 10 to 15 mm Hg
in the systolic blood pressure with a corresponding drop in di-
astolic pressure and an increased pulse rate (by 10 or more beats
per minute) is indicative of orthostatic or postural hypotension.
FLUID INTAKE AND OUTPUT. The measurement and record-
ing of all fluid intake and output (I & O) during a 24-hour pe-
riod provides important data about the clients fluid and
electrolyte balance. Generally, intake and output are measured
for hospitalized at-risk clients.
The unit used to measure intake and output is the milliliter
(mL) or cubic centimeter (cc); these are equivalent metric units
of measurement. In household measures, 30 mL is roughly
equivalent to 1 fluid ounce, 500 mLis about 1 pint, and 1,000 mL
is about 1 quart. To measure fluid intake, nurses convert house-
hold measures such as a glass, cup, or soup bowl to metric units.
Most agencies provide conversion tables, since the sizes of
dishes vary from agency to agency. Such a table is often provided
on or with the bedside I & O record. Examples of equivalents are
given in Box 524.
Most agencies have a form for recording I & O, usually a
bedside record on which the nurse lists all items measured and
the quantities per shift (Figure 52-14 ). Some agencies have
another form for recording the specifics of intravenous fluids,
such as the type of solution, additives, time started, amounts ab-
sorbed, and amounts remaining per shift.
It is important to inform clients, family members, and all
caregivers that accurate measurements of the clients fluid in-
take and output are required, explaining why and emphasizing
the need to use a bedpan, urinal, commode, or in-toilet collec-
tion device (unless a urinary drainage system is in place). In-
struct the client not to put toilet tissue into the container with
urine. Clients who wish to be involved in recording fluid intake
measurements need to be taught how to compute the values and
what foods are considered fluids.
To measure fluid intake, the nurse records on the I & O form
each fluid item taken (if the client has not already done so),
specifying the time and type of fluid. All of the following fluids
need to be recorded:
Oral fluids. Water, milk, juice, soft drinks, coffee, tea,
cream, soup, and any other beverages. Include water taken
with medications. To assess the amount of water taken
from a water pitcher, measure what remains and subtract
this amount from the volume of the full pitcher. Then refill
the pitcher.
Ice chips. Record the fluid as approximately one-half the vol-
ume of the ice chips. For example, if the ice chips fill a cup
holding 200 mL and the client consumed all of the ice chips,
the volume consumed would be recorded as 100 mL.
Foods that are or tend to become liquid at room temperature.
These include ice cream, sherbert, custard, and gelatin. Do
not measure foods that are pureed, because purees are sim-
ply solid foods prepared in a different form.
Tube feedings. Remember to include the 30- to 60-mL water
flush at the end of intermittent feedings or during continuous
feedings.
Parenteral fluids. The exact amount of intravenous fluid ad-
ministered is to be recorded, since some fluid containers may
be overfilled. Blood transfusions are included.
Intravenous medications. Intravenous medications that are
prepared with solutions such as normal saline (NS) and are
BOX 524 Commonly Used Fluid Containers
and Their Volumes
Water glass 200 mL
Juice glass 120 mL
Cup 180 mL
Soup bowl
Adult 180 mL
Child 100 mL
Teapot 240 mL
Creamer
Large 90 mL
Small 30 mL
Water pitcher 1,000 mL
Jello, custard dish 100 mL
Ice cream dish 120 mL
Paper cup
Large 200 mL
Small 120 mL
Figure 52-14 A sample 24-hour fluid intake and output record.
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1447
administered as an intermittent or continuous infusion must
also be included (e.g., ceftazidime 1 g in 50 mL of sterile wa-
ter). Most intravenous medications are mixed in 50 to 100 mL
of solution.
Catheter or tube irrigants. Fluid used to irrigate urinary
catheters, nasogastric tubes, and intestinal tubes must be
measured and recorded if not immediately withdrawn.
To measure fluid output, measure the following fluids (re-
member to observe appropriate infection control precautions):
Urinary output. Following each voiding, pour the urine into
a measuring container, observe the amount, and record it and
the time of voiding on the I & O form. For clients with reten-
tion catheters, empty the drainage bag into a measuring con-
tainer at the end of the shift (or at prescribed times if output
is to be measured more often). Note and record the amount
of urine output. In intensive care areas, urine output often is
measured hourly. If the client is incontinent of urine, esti-
mate and record these outputs. For example, for an inconti-
nent client the nurse might record Incontinent 3 or
Drawsheet soaked in 12-in. diameter. Amore accurate es-
timate of the urine output of infants and incontinent clients
may be obtained by first weighing diapers or incontinent
pads that are dry, and then subtracting this weight from the
weight of the soiled items. Each gram of weight left after
subtracting is equal to 1 mL of urine. If urine is frequently
soiled with feces, the number of voidings may be recorded
rather than the volume of urine.
Vomitus and liquid feces. The amount and type of fluid and
the time need to be specified.
Tube drainage, such as gastric or intestinal drainage.
Wound drainage and draining fistulas. Wound drainage may
be recorded by documenting the type and number of dress-
ings or linen saturated with drainage or by measuring the ex-
act amount of drainage collected in a vacuum drainage (e.g.,
Hemovac) or gravity drainage system.
Fluid intake and output measurements are totaled at the end
of the shift (every 8 to 12 hours), and the totals are recorded in
the clients permanent record. In intensive care areas, the nurse
may record intake and output hourly. Usually the staff on night
shift totals the amounts of I & O recorded for each shift and
records the 24-hour total.
To determine whether the fluid output is proportional to fluid
intake or whether there are any changes in the clients fluid status,
the nurse (a) compares the total 24-hour fluid output measurement
with the total fluid intake measurement and (b) compares both to
previous measurements. Urinary output is normally equivalent to
the amount of fluids ingested; the usual range is 1,500 to 2,000 mL
in 24 hours, or 40 to 80 mL in 1 hour (0.5 mL/kg/hour). Clients
whose output substantially exceeds intake are at risk for fluid vol-
ume deficit. By contrast, clients whose intake substantially ex-
ceeds output are at risk for fluid volume excess. In assessing the
clients fluid balance it is important to consider additional factors
that may affect intake and output. The client who is extremely di-
aphoretic or who has rapid, deep respirations has fluid losses that
cannot be measured but must be considered in evaluating fluid
status.
When there is a significant discrepancy between intake and
output or when fluid intake or output is inadequate (for exam-
ple, a urine output of less than 500 mL in 24 hours or less than
0.5 mL per kilogram per hour in an adult), this information
should be reported to the charge nurse or primary care provider.
Laboratory Tests
Many laboratory studies are conducted to determine the clients
fluid, electrolyte, and acidbase status. Some of the more com-
mon tests are discussed here.
SERUM ELECTROLYTES. Serum electrolyte levels are often
routinely ordered for any client admitted to the hospital as a
screening test for electrolyte and acidbase imbalances.
Serum electrolytes also are routinely assessed for clients at
risk in the community, for example, clients who are being
treated with a diuretic for hypertension or heart failure. The
most commonly ordered serum tests are for sodium, potas-
sium, chloride, magnesium, and bicarbonate ions. Normal val-
ues of commonly measured electrolytes are shown in Box
525. Some primary care providers use a diagram format for
keeping track of the clients electrolytes when documenting in
their progress notes. See Figure 52-15
.
BOX 525 Normal Electrolyte Values
for Adults
*
VENOUS BLOOD
Sodium 135145 mEq/L
Potassium 3.55.0 mEq/L
Chloride 95108 mEq/L
Calcium (total) 4.55.5 mEq/L or 8.510.5 mg/dL
(ionized) 56% of total calcium (2.5 mEq/L or
4.05.0 mg/dL)
Magnesium 1.52.5 mEq/L or 1.62.5 mg/dL
Phosphate (phosphorus) 1.82.6 mEq/L or 2.5 4.5 mg/dL
Serum osmolality 280300 mOsm/kg water
*
Normal laboratory values vary from agency to agency.
Na
K
Cl
BUN
CR
CO
2
A.
142
4.2
102
10
0.8
28
B.
Figure 52-15 A, Format for a diagram of serum electrolyte results.
B, Example that may be seen in a primary care providers
documentation notes.
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1448
COMPLETE BLOOD COUNT (CBC). The complete blood
count, another basic screening test, includes information about
the hematocrit (Hct). The hematocrit measures the volume
(percentage) of whole blood that is composed of RBCs. Be-
cause the hematocrit is a measure of the volume of cells in re-
lation to plasma, it is affected by changes in plasma volume.
Thus the hematocrit increases with severe dehydration and de-
creases with severe overhydration. Normal hematocrit values
are 40% to 54% (men) and 37% to 47% (women).
OSMOLALITY. Serum osmolality is a measure of the solute
concentration of the blood. The particles included are sodium
ions, glucose, and urea (blood urea nitrogen, or BUN). Serum
osmolality can be estimated by doubling the serum sodium,
because sodium and its associated chloride ions are the major
determinants of serum osmolality. Serum osmolality values
are used primarily to evaluate fluid balance. Normal values are
280 to 300 mOsm/kg. An increase in serum osmolality indi-
cates a fluid volume deficit; a decrease reflects a fluid volume
excess.
Urine osmolality is a measure of the solute concentration
of urine. The particles included are nitrogenous wastes, such
as creatinine, urea, and uric acid. Normal values are 500 to
800 mOsm/kg. An increased urine osmolality indicates a
fluid volume deficit; a decreased urine osmolality reflects a
fluid volume excess.
URINE pH. Measurement of urine pH may be obtained by lab-
oratory analysis or by using a dipstick on a freshly voided
specimen. Because the kidneys play a critical role in regulat-
ing acidbase balance, assessment of urine pH can be useful in
determining whether the kidneys are responding appropriately
to acidbase imbalances. Normally the pH of the urine is rel-
atively acidic, averaging about 6.0, but a range of 4.6 to 8.0 is
considered normal. In metabolic acidosis, urine pH should de-
crease as the kidneys excrete hydrogen ions; in metabolic al-
kalosis, the pH should increase.
URINE SPECIFIC GRAVITY. Specific gravity is an indicator of
urine concentration that can be performed quickly and easily by
nursing personnel. Normal specific gravity ranges from 1.005 to
1.030 (usually 1.010 to 1.025). When the concentration of
solutes in the urine is high, the specific gravity rises; in very di-
lute urine with few solutes, it is abnormally low.
URINE SODIUM AND CHLORIDE EXCRETION. These are indi-
cators of renal perfusion and can provide useful information
about a clients fluid status. With hypovolemia, aldosterone
will be secreted. This will cause reabsorption of sodium and
chloride which will result in decreased levels of sodium and
chloride, less than 20 mEq/L each (Elgart, 2004).
ARTERIAL BLOOD GASES. Arterial blood gases (ABGs) are per-
formed to evaluate the clients acidbase balance and oxy-
genation. Arterial blood is used because it provides a truer
reflection of gas exchange in the pulmonary system than ve-
nous blood. Blood gases may be drawn by laboratory techni-
cians, respiratory therapy personnel, or nurses with
specialized skills. Because a high-pressure artery is used to
obtain blood, it is important to apply pressure to the puncture
site for 5 minutes after the procedure to reduce the risk of
bleeding or bruising.
Six measurements are commonly used to interpret arterial
blood gas tests (Simpson, 2004):
pH: a measure of the relative acidity or alkalinity of the
blood. The greater the number of hydrogen ions, the more
acidic the solution is. The normal range for pH is narrow, and
death may ensue with pH values below 6.8 or above 7.8.
PaO
2
: the pressure exerted by oxygen dissolved in the
plasma of arterial blood; an indirect measure of blood oxy-
gen content. This measure, representing one of the two forms
in which oxygen is transported in the blood, accounts for
only about 3% of oxygen content in the blood.
PaCO
2
: the partial pressure of carbon dioxide in arterial
plasma; the respiratory component of acidbase determination.
Carbon dioxide is regulated by the lungs, and the PaCO
2
is used
to determine if an acidbase imbalance is respiratory in origin.
Bicarbonate HCO
3
: a measure of the metabolic component

of acidbase balance.
Base excess (BE): a calculated value of bicarbonate levels,
also reflective of the metabolic component of acidbase bal-
ance. If the number is preceded by a plus sign, it is a base ex-
cess and indicates alkalosis; if preceded by a minus sign, it is
a base deficit and indicates acidosis.
Oxygen saturation (SpO
2
): the percentage of hemoglobin
saturated (combined) with oxygen. This represents the other
form in which oxygen is transported in the blood and ac-
counts for about 97% of the oxygen in the blood.
Normal ABG values are listed in Box 526. Changes seen in
common acidbase imbalances are summarized in Table 529.
Note that although the PaO
2
and SpO
2
are important for assess-
ing respiratory status, they generally do not provide useful in-
formation for assessing acidbase balance and so are not
included in this table.
When evaluating ABG results to determine acidbase bal-
ance, it is important to use a systematic approach such as the one
outlined in Box 527. Nurses need to assess each measurement
individually, then look at the interrelationships to determine
what type of acidbase imbalance may be present.
BOX 526 Normal Values of Arterial
Blood Gases
*
pH 7.357.45
PaO
2
80100 mm Hg
PaCO
2
3545 mm Hg
HCO
3
2226 mEq/L
Base excess 2 to 2 mEq/L
O
2
saturation 9598%
*
Some normal values will vary according to the kind of test carried out in the labo-
ratory. Nurses are advised to use the normal values issued by the agency when in-
terpreting laboratory results.
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Diagnosing
NANDA includes the following diagnostic labels that relate to
fluid and acidbase imbalances:
Deficient Fluid Volume: Decreased intravascular, interstitial,
and/or intracellular fluid. This refers to dehydration, water
loss alone without change in sodium.
Excess Fluid Volume: Increased isotonic fluid retention.
Risk for Imbalanced Fluid Volume: At risk for a decrease, in-
crease, or rapid shift from one to the other of intravascular,
interstitial, and/or intracellular fluid. This refers to body fluid
loss, gain, or both.
Risk for Deficient Fluid Volume: At risk for experiencing
vascular, cellular, or intracellular dehydration.
Impaired Gas Exchange: Excess or deficit in oxygenation and/or
carbon dioxide elimination at the alveolar-capillary membrane.
BOX 527 Interpreting ABGs Do You Have a Match?
1. Look at each number separately.
Label the pH:
If the pH is less than 7.35, the problem is acidosis.
If the pH is greater than 7.45, the problem is alkalosis.
Label the PaCO
2
:
If the PaCO
2
is less than 35 mm Hg, more carbon dioxide is
being exhaled than normal and indicates alkalosis.
If the PaCO
2
is greater than 45 mm Hg, less carbon dioxide
is being exhaled than normal and indicates acidosis.
Label the bicarbonate:
If the HCO
3
is less than 22 mEq/L, bicarbonate levels are

lower than normal, indicating acidosis.
If the HCO
3
is greater than 26 mEq/L, bicarbonate levels are

higher than normal, indicating alkalosis.
2. Determine the cause of the acidbase imbalance.
Look at the pHis it acidosis or alkalosis?
3. Determine if the origin of the imbalance is respiratory or metabolic.
Check the PaCO
2
and HCO
3
which one MATCHES the same

acidbase status as the pH?
EXAMPLE
pH 7.33 (acidosis)
PaCO
2
55 (acidosis)
HCO
3
29 (alkalosis)
Cause of imbalance (hint: look at pH) acidosis.
PaCO
2
(acidosis) MATCHES the pH (acidosis) respiratory
problem
Client has respiratory acidosis.
4. Look for evidence of compensation.
Look at the value that does NOT match the pH:
If it (e.g., PaCO
2
or HCO
3
) is within normal range, there is no
compensation.
If it (e.g., PaCO
2
or HCO
3
) is above or below normal range,
the body is compensating.
EXAMPLES
a. In respiratory acidosis (pH < 7.35, PaCO
2
> 45 mm Hg), if
the HCO
3
is greater than 26 mEq/L, the kidneys are retain-

ing bicarbonate to minimize the acidosis: renal compensation.
b. In respiratory alkalosis (pH > 7.45, PaCO
2
< 35 mm Hg),
if the HCO
3
is less than 22 mEq/L, the kidneys are ex-

creting bicarbonate to minimize the alkalosis: again, renal
compensation.
c. In metabolic acidosis (pH < 7.35, HCO
3
< 22 mEq/L),
if the PaCO
2
is less than 35 mm Hg, carbon dioxide is
being blown off to minimize the acidosis: respiratory
compensation.
d. In metabolic alkalosis (pH > 7.45, HCO
3
> 26 mEq/L), if
the PaCO
2
is greater than 45 mm Hg, carbon dioxide is
being retained to compensate for excess base: again, re-
spiratory compensation.
Note: If the value that doesnt match (e.g., PaCO
2
or HCO
3
) is above or below normal
and the pH is within normal range, the body has completely compensated. Complete
compensation takes time to develop and is the result of a chronic condition (e.g.,
chronic respiratory acidosis with COPD).
TABLE 529 Arterial Blood Gas Values in Common AcidBase Disorders
DISORDER ABG VALUES
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
pH
PaCO
2
HCO
3
pH
PaCO
2
HCO
3
pH
PaCO
2
HCO
3
pH
PaCO
2
HCO
3
< 7.35
> 45 mm Hg (excess CO
2
and carbonic acid)
Normal; or >26 mEq/L with renal compensation
> 7.45
< 35 mm Hg (inadequate CO
2
and carbonic acid)
Normal; or < 22 mEq/L with renal compensation
< 7.35
Normal; or < 35 mm Hg with respiratory compensation
< 22 mEq/L (inadequate bicarbonate)
> 7.45
Normal; or > 45 mm Hg with respiratory compensation
> 26 mEq/L (excess bicarbonate)
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Prevent associated risks (tissue breakdown, decreased car-
diac output, confusion, other neurologic signs).
Obviously, goals will vary according to the diagnosis and
defining characteristics for each individual. Appropriate pre-
ventive and corrective nursing interventions that relate to these
must be identified. Specific nursing activities can be selected to
meet the clients individual needs. Examples of application of
these using NANDA, NIC, and NOC designations are shown in
Identifying Nursing Diagnoses, Outcomes, and Interventions
and in the Nursing Care Plan and the Concept Map at the end of
this chapter. Examples of NIC interventions related to fluid,
electrolyte, and acidbase balance include the following:
Acidbase management
Electrolyte management
Fluid monitoring
Hypovolemia management
Intravenous (IV) therapy
Specific nursing activities associated with each of these in-
terventions can be selected to meet the individual needs of the
client.
Nursing activities to meet goals and outcomes related to
fluid, electrolyte, and acidbase imbalances are discussed in
the next section. These include (a) monitoring fluid intake and
output, cardiovascular and respiratory status, and results of lab-
oratory tests; (b) assessing the clients weight; location and ex-
tent of edema, if present; skin turgor and skin status; specific
gravity of urine; and level of consciousness and mental status;
Clinical applications of selected diagnoses are shown in
Identifying Nursing Diagnoses, Outcomes, and Interventions
and in the Nursing Care Plan and the Concept Map at the end of
this chapter.
Fluid, electrolyte, and acidbase imbalances affect many
other body areas and as a consequence may be the etiology of
other nursing diagnoses, such as
Impaired Oral Mucous Membrane related to fluid volume
deficit.
Impaired Skin Integrity related to dehydration and/or edema.
Decreased Cardiac Output related to hypovolemia and/or
cardiac dysrhythmias secondary to electrolyte imbalance
(K
or Mg
2
).
Ineffective Tissue Perfusion related to decreased cardiac out-
put secondary to fluid volume deficit or edema.
Activity Intolerance related to hypervolemia.
Risk for Injury related to calcium shift out of bones into ex-
tracellular fluids.
Acute Confusion related to electrolyte imbalance.
Planning
When planning care the nurse identifies nursing interventions
that will assist the client to achieve these broad goals:
Maintain or restore normal fluid balance.
Maintain or restore normal balance of electrolytes in the in-
tracellular and extracellular compartments.
Maintain or restore pulmonary ventilation and oxygenation.
NURSING
DIAGNOSIS/
DEFINITION
SAMPLE DESIRED
OUTCOMES*/
DEFINITION INDICATORS
SELECTED
INTERVENTIONS*/
DEFINITION SAMPLE NIC ACTIVITIES
Fluid Management
[4120]/Promotion of
fluid balance and pre-
vention of complica-
tions resulting from
abnormal or unde-
sired fluid levels
Not
compromised:
24-hour
intake and
output
Stable body
weight
No:
Adventitious
breath
sounds
Neck vein
distention
Fluid Balance
[0601]/Water balance
in the intracellular and
extracellular compart-
ments of the body
*
The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention. Outcomes, indicators, inter-
ventions, and activites selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.
Excess Fluid Volume/
Increased isotonic fluid
retention
Assess location and extent of edema

on scale from 1 to 4
Monitor for indications of fluid over-

load/retention (e.g., crackles, ele-
vated BP, edema, neck vein
distention) as appropriate
Maintain accurate intake and output

record
Weigh daily and monitor trends
Consult primary care provider if signs

and symptoms of fluid volume ex-
cess persist or worsen
IDENTIFYING NURSING DIAGNOSES, OUTCOMES, AND INTERVENTIONS
Clients with Fluid Volume Excess
DATA CLUSTER Tom Bricker, a 67-year-old pensioner who has a history of heart disease, has experienced a weight gain of 4 to 5 kg (9 to 11
lb) during the past month. He states his rings are too tight to remove, his ankles are swollen, his heart pounds at times, he gets breathless with
exertion, and he feels bloated. Physical findings reveal jugular vein distention above 3 cm; delayed emptying of hand veins; bounding pulse (86);
pitting edema in feet, ankles, and lower legs; and moist lung sounds (rales/crackles).
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(c) fluid intake modifications; (d) dietary changes; (e) par-
enteral fluid, electrolyte, and blood replacement; and
(f) other appropriate measures such as administering pre-
scribed medications and oxygen, providing skin care and oral
hygiene, positioning the client appropriately, and scheduling
rest periods.
Planning for Home Care
To provide for continuity of care, the clients needs for assis-
tance with care in the home need to be considered. Home
care planning includes assessment of the clients and fam-
ilys resources and abilities for care, and the need for refer-
NURSING
DIAGNOSIS/
DEFINITION
SAMPLE DESIRED
OUTCOMES
*
/
DEFINITION INDICATORS
SELECTED
INTERVENTIONS
*
/
DEFINITION SAMPLE NIC ACTIVITIES
AcidBase Manage-
ment: Respiratory
Acidosis [1913]/
Promotion of
acidbase balance
and prevention of
complications result-
ing from serum PCO
2
levels higher than
desired
Not
compromised
Depth of
inspiration
Auscultated
breath
sounds
Respiratory Status:
Ventilation [0403]/
Movement of air in
and out of the lungs
*
The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention. Outcomes, indicators, inter-
ventions, and activites selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.
Impaired Gas
Exchange/Excess or deficit
in oxygenation and/or
carbon dioxide elimination
at the alveolar-capillary
membrane
Monitor respiratory pattern
Monitor ABG levels for decreasing pH

level, as appropriate
Monitor neurological status (e.g., level

of consciousness and confusion)
Monitor determinants of tissue oxy-

gen delivery (e.g., PaO
2
, SaO
2
, hemo-
globin levels)
Provide mechanical ventilatory sup-

port if necessary
IDENTIFYING NURSING DIAGNOSES, OUTCOMES, AND INTERVENTIONS
Clients with Impaired Gas Exchange
DATA CLUSTER Fred Boysniak was admitted to emergency after being found with an empty bottle of morphine tablets by his bed. He appears
very lethargic and stuporous; pulse is 120, respiration 12 and very shallow. Blood gases reveal pH of 7.28, PaCO
2
49 mm Hg, and HCO
3
25
mEq/L.
rals and home health services. The accompanying Home
Care Assessment describes the specific assessment data re-
quired to establish a home care plan. Based on the data gath-
ered in assessment of the home situation, the nurse tailors the
teaching plan for the client and family (see Client Teaching
on page 1453).
Implementing
Promoting Wellness
Most people rarely think about their fluid, electrolyte, or
acidbase balance. They know it is important to drink adequate
HOME CARE ASSESSMENT Fluid, Electrolyte, and AcidBase Balance
CLIENT
Risk factors for imbalances: The clients age, medications required
such as diuretic therapy or corticosteroids, and presence of chronic
diseases such as diabetes mellitus, heart disease, lung disease, or
dementia (see Box 523 on p. 1445)
Self-care abilities for maintaining food and fluid intake: Mobility;
ability to chew and swallow, to access fluids and respond to thirst,
to purchase food and prepare a balanced diet
Current level of knowledge (as appropriate) about: Prescribed diet,
any fluid restrictions, activity restrictions, actions and side effects of
prescribed medications, regular weight monitoring, gastric tube
care and enteral feedings, central line or PICC catheter care, and
parenteral fluids and nutrition
FAMILY
Caregiver availability, skills, and responses: Availability and willing-
ness to assume responsibility for care, knowledge and ability to
provide assistance with preparing food and maintaining adequate
intake of food and fluids, knowledge of risk factors and early warn-
ing signs of problems
Family role changes and coping: Effect on financial status, parent-
ing and spousal roles, social roles
Alternate potential primary or respite caregivers: For example,
other family members, volunteers, church members, paid care-
givers or housekeeping services; available community respite care
(e.g., adult day care, senior centers)
COMMUNITY
Current knowledge of and experience with community resources:
Home health agencies, organizations that offer financial assistance
or assistance with food preparation, Meals on Wheels or meal ser-
vices (e.g., at senior centers, homeless shelters), pharmacies,
home intravenous services, respiratory care services
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1452
fluids and consume a balanced diet, but they may not under-
stand the potential effects when this is not done. Nurses can pro-
mote clients health by providing wellness teaching that will
help them maintain fluid and electrolyte balance.
Enteral Fluid and Electrolyte Replacement
Fluids and electrolytes can be provided orally in the home and
hospital if the clients health permits, that is, if the client is not
vomiting, has not experienced an excessive fluid loss, and has
CLIENT TEACHING Promoting Fluid and Electrolyte Balance
Consume six to eight glasses of water daily.
Avoid excess amounts of foods or fluids high in salt, sugar, and
caffeine.
Eat a well-balanced diet. Include adequate amounts of milk or milk
products to maintain bone calcium levels.
Limit alcohol intake because it has a diuretic effect.
Increase fluid intake before, during, and after strenuous exercise,
particularly when the environmental temperature is high, and re-
place lost electrolytes from excessive perspiration as needed with
commercial electrolyte solutions.
Maintain normal body weight.
Learn about and monitor side effects of medications that affect
fluid and electrolyte balance (e.g., diuretics) and ways to handle
side effects.
Recognize possible risk factors for fluid and electrolyte imbalance
such as prolonged or repeated vomiting, frequent watery stools, or
inability to consume fluids because of illness.
Seek prompt professional health care for notable signs of fluid im-
balance such as sudden weight gain or loss, decreased urine vol-
ume, swollen ankles, shortness of breath, dizziness, or confusion.
CLIENT TEACHING Home Care and Fluid, Electrolyte, and AcidBase Balance
MONITORING FLUID INTAKE AND OUTPUT
Teach and provide the rationale for monitoring fluid intake and
output to the client and family as appropriate. Include how to
use a commode or collection device (hat) in the toilet, how to
empty and measure urinary catheter drainage, and how to count
or weigh diapers.
Instruct and provide the rationale for regular weight monitoring
to the client and family. Weigh at the same time of day, using the
same scale and with the client wearing the same amount of
clothing.
Educate and provide the rationale to the client and family on when
to contact a health care professional, such as in the cases of a sig-
nificant change in urine output; any change of 5 pounds or more
in a 1- to 2-week period; prolonged episodes of vomiting, diarrhea,
or inability to eat or drink; dry, sticky mucous membranes; extreme
thirst; swollen fingers, feet, ankles, or legs; difficulty breathing,
shortness of breath, or rapid heartbeat; and changes in behavior
or mental status.
MAINTAINING FOOD AND FLUID INTAKE
Instruct the client and family about any diet or fluid restrictions,
such as a low-sodium diet.
Teach family members the rationale for the importance of offering
fluids regularly to clients who are unable to meet their own needs
because of age, impaired mobility or cognition, or other conditions
such as impaired swallowing due to a stroke.
If the client is on enteral or intravenous fluids and feeding at home,
teach and provide the underlying rationale to caregivers about
proper administration and care. Contact a home health or home
intravenous service to provide services and teaching.
SAFETY
Instruct and provide the rationale to the client to change positions
slowly if appropriate, especially when moving from a supine to a
sitting or standing position.
Inform and provide the rationale to the client and family about the
importance of good mouth and skin care. Teach the client to
change positions frequently and to elevate the feet on a stool
when sitting for a long period.
Teach the client and family how to care for intravenous access sites
or gastric tubes. Include what to do if tubes become dislodged.
MEDICATIONS
Emphasize the importance of and rationale for taking medications
as prescribed.
Instruct clients taking diuretics to take the medication in the morn-
ing. If a second daily dose is prescribed, they should take it in the
late afternoon to avoid disrupting sleep to urinate.
Inform clients about any expected side effects of prescribed med-
ications and how to handle them (e.g., if a potassium-depleting di-
uretic is prescribed, increase intake of potassium-rich foods; if
taking a potassium-sparing diuretic, avoid excess potassium intake
such as using a salt substitute).
Teach clients when to contact their primary care provider, for ex-
ample, if they are unable to take a prescribed medication or have
signs of an allergic or toxic reaction to a medication.
MEASURES SPECIFIC TO CLIENTS PROBLEM
Provide instructions and rationale specific to the clients fluid, elec-
trolyte, or acidbase imbalance, such as
a. Fluid volume deficit.
b. Risk for fluid volume deficit.
c. Fluid volume excess.
REFERRALS
Make appropriate referrals to home health or community social ser-
vices for assistance with resources such as meals, meal preparation
and food, intravenous infusions and access, enteral feedings, and
homemaker or home health aide services to help with ADLs.
COMMUNITY AGENCIES AND OTHER SOURCES OF HELP
Provide information about companies or agencies that can provide
durable medical equipment such as commodes, lift chairs, or hos-
pital beds for purchase, for rental, or free of charge.
Provide a list of sources for supplies such as catheters and
drainage bags, measuring devices, tube feeding formulas, and
electrolyte replacement drinks.
Suggest additional sources of information and help such as the
American Dietetic Association, the American Heart Association,
and the American Lung Association.
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1453
an intact gastrointestinal tract and gag and swallow reflexes.
Clients who are unable to ingest solid foods may be able to in-
gest fluids.
FLUID INTAKE MODIFICATIONS. Increased fluids (ordered as
push fluids) are often prescribed for clients with actual or
potential fluid volume deficits arising, for example, from mild
diarrhea or mild to moderate fevers. Guidelines for helping
clients increase fluid intake are shown in the above Practice
Guidelines.
Restricted fluids may be necessary for clients who have fluid
retention (fluid volume excess) as a result of renal failure, con-
gestive heart failure, SIADH, or other disease processes. Fluid
restrictions vary from nothing by mouth to a precise amount
ordered by a primary care provider. The restriction of fluids can
be difficult for some clients, particularly if they are experienc-
ing thirst. Guidelines for helping clients restrict fluid intake are
shown in Practice Guidelines.
DIETARY CHANGES. Specific fluid and electrolyte imbal-
ances may require simple dietary changes. For example,
clients receiving potassium-depleting diuretics need to be in-
formed about foods with a high potassium content (e.g., ba-
nanas, oranges, and leafy greens). Some clients with fluid
retention need to avoid foods high in sodium. Most healthy
clients can benefit from foods rich in calcium.
ORAL ELECTROLYTE SUPPLEMENTS. Some clients can bene-
fit from oral supplements of electrolytes, particularly when a
medication is prescribed that affects electrolyte balance, when
dietary intake is inadequate for a specific electrolyte, or when
fluid and electrolyte losses are excessive as a result of, for ex-
ample, excessive perspiration.
Corticosteroids and many diuretics can cause too much
potassium to be eliminated through the kidneys. For clients tak-
ing these medications, potassium supplements may be pre-
scribed. Instruct clients taking oral potassium supplements to
PRACTICE GUIDELINES Facilitating Fluid Intake
Explain to the client the reason for the required intake and the
specific amount needed. This provides a rationale for the re-
quirement and promotes compliance.
Establish a 24-hour plan for ingesting the fluids. For the hospi-
talized or long-term care client, half of the total volume is given
during the day shift, and the other half is divided between the
evening and night shifts, with most of that ingested during the
evening shift. For example, if 2,500 mL is to be ingested in 24
hours, the plan may specify 73 (1,500 mL); 311 (700 mL);
and 117 (300 mL). Try to avoid the ingestion of large
amounts of fluid immediately before bedtime to prevent the
need to urinate during sleeping hours.
Set short-term outcomes that the client can realistically meet.
Examples include ingesting a glass of fluid every hour while
awake or a pitcher of water by 12 noon.
Identify fluids the client likes and make available a variety of
those items, including fruit juices, soft drinks, and milk (if al-
lowed). Remember that beverages such as coffee and
tea have a diuretic effect, so their consumption should be
limited.
Help clients to select foods that tend to become liquid at room
temperature (e.g., gelatin, ice cream, sherbet, custard), if these
are allowed.
For clients who are confined to bed, supply appropriate cups,
glasses, and straws to facilitate appropriate fluid intake and
keep the fluids within easy reach.
Make sure fluids are served at the appropriate temperature: hot
fluids hot and cold fluids very cold.
Encourage clients when possible to participate in maintaining
the fluid intake record. This assists them to evaluate the
achievement of desired outcomes.
Be alert to any cultural implications of food and fluids. Some
cultures may restrict certain foods and fluids and view others
as having healing properties.
PRACTICE GUIDELINES Helping Clients Restrict Fluid Intake
Explain the reason for the restricted intake and how much and
what types of fluids are permitted orally. Many clients need to
be informed that ice chips, gelatin, and ice cream, for example,
are considered fluid.
Help the client decide the amount of fluid to be taken with
each meal, between meals, before bedtime, and with medica-
tions. For the hospitalized or long-term care client, half the to-
tal volume is scheduled during the day shift, when the client is
most active, receives two meals, and most oral medications. A
large part of the remainder is scheduled for the evening shift
to permit fluids with meals and evening visitors.
Identify fluids or fluidlike substances the client likes and make
sure that these are provided, unless contraindicated. A client
who is allowed only 200 mL of fluid for breakfast, for example,
should receive the type of fluid the client favors.
Set short-term goals that make the fluid restriction more toler-
able. For example, schedule a specified amount of fluid at one
or two hourly intervals between meals. Some clients may pre-
fer fluids only between meals if the food provided at mealtime
helps relieve thirst.
Place allowed fluids in small containers such as a 4-ounce juice
glass to allow the perception of a full container.
Periodically offer the client ice chips as an alternative to water,
because ice chips when melted are approximately half of the
frozen volume.
Provide frequent mouth care and rinses to reduce the thirst
sensation.
Instruct the client to avoid ingesting or chewing salty or sweet
foods (hard candy or gum), because these foods tend to
produce thirst. Sugarless gum may be an alternative for
some clients.
Encourage the client when possible to participate in maintain-
ing the fluid intake record.
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1454
take the medication with juice to mask the unpleasant taste and
reduce the possibility of gastric distress. Emphasize the impor-
tance of taking the medication as prescribed and seeing their
primary care provider on a regular basis. Because hyperkalemia
can have serious cardiac effects, clients should never increase
the amount of potassium being taken without an order to do so.
In addition, inform clients that most salt substitutes contain
potassium, so it is important to consult with the primary care
provider before using salt substitutes.
People who ingest insufficient milk and milk products bene-
fit from calcium supplements. The recommended daily al-
lowance for calcium is 1,000 to 1,500 mg. It is generally
recommended that postmenopausal women take 1,500 mg of
calcium per day to reduce the risk of osteoporosis. Long-term
use of corticosteroid drugs can also cause calcium loss from the
bone, and calcium supplements may help reduce this loss.
Clients who take supplemental calcium need to maintain a fluid
intake of at least 2,500 mL per day (unless contraindicated) to
reduce the risk of kidney stones, which are commonly com-
posed of calcium salts.
Although routine supplements for other electrolytes gener-
ally are not recommended, clients who have poor dietary habits,
who are malnourished, or who have difficulty accessing or eat-
ing fresh fruits and vegetables may benefit from electrolyte sup-
plements. A daily multiple vitamin with minerals may achieve
the desired goal. People who engage in strenuous activity in a
warm environment need to be encouraged to replace water and
electrolytes lost through excessive perspiration by consuming a
sports drink such as Gatorade or another commercial fluid and
electrolyte solution.
Liquid nutritional supplements are often given to clients who
are malnourished or have poor eating habits. They are used with
frequency in older adults to bolster nutritional status and caloric
intake. It is very important to be a label reader of the product
and to be aware of the contents of the supplement. Some of them
are very high in protein and high in potassium, which may be
contraindicated in an individual with impaired renal function.
Parenteral Fluid and Electrolyte Replacement
Intravenous (IV) fluid therapy is essential when clients are un-
able to take food and fluids orally. It is an efficient and effective
method of supplying fluids directly into the intravascular fluid
compartment and replacing electrolyte losses. Intravenous fluid
therapy is usually ordered by the primary care provider. The
nurse is responsible for administering and maintaining the ther-
apy and for teaching the client and significant others how to
continue the therapy at home if necessary.
INTRAVENOUS SOLUTIONS. Intravenous solutions can be
classified as isotonic, hypotonic, or hypertonic. Most IV solu-
tions are isotonic, having the same concentration of solutes as
blood plasma. Isotonic solutions are often used to restore vas-
cular volume. Hypertonic solutions have a greater concentra-
tion of solutes than plasma; hypotonic solutions have a lesser
concentration of solutes. Table 5210 provides examples of IV
solutions and nursing implications.
IV solutions can also be categorized according to their pur-
pose. Nutrient solutions contain some form of carbohydrate
(e.g., dextrose, glucose, or levulose) and water. Water is sup-
plied for fluid requirements and carbohydrate for calories and
energy. For example, 1 L of 5% dextrose provides 170 calories.
Nutrient solutions are useful in preventing dehydration and ke-
tosis but do not provide sufficient calories to promote wound
healing, weight gain, or normal growth in children. Common
nutrient solutions are 5% dextrose in water (D5W) and 5% dex-
trose in 0.45% sodium chloride (dextrose in half-strength
saline).
Electrolyte solutions contain varying amounts of cations and
anions. Commonly used solutions are normal saline (0.9%
sodium chloride solution), Ringers solution (which contains
sodium, chloride, potassium, and calcium), and lactated
Ringers solution (which contains sodium, chloride, potassium,
calcium, and lactate). Lactate is metabolized in the liver to form
bicarbonate HCO
3
. Saline and balanced electrolyte solutions

commonly are used to restore vascular volume, particularly
TABLE 5210 Selected Intravenous Solutions
TYPE/EXAMPLES COMMENTS/NURSING IMPLICATIONS
Isotonic Solutions
0.9% NaCl (normal saline)
Lactated Ringers (a balanced electrolyte solution)
5% dextrose in water (D5W)
Hypotonic Solutions
0.45% NaCl (half normal saline)
0.33% NaCl (one-third normal saline)
Hypertonic Solutions
5% dextrose in normal saline (D5NS)
5% dextrose in 0.45% NaCl (D5 1/2NS)
5% dextrose in lactated Ringers (D5LR)
Isotonic solutions such as NS and lactated Ringers initially remain in the vascular
compartment, expanding vascular volume. Assess clients carefully for signs of
hypervolemia such as bounding pulse and shortness of breath.
D5W is isotonic on initial administration but provides free water when dextrose is
metabolized, expanding intracellular and extracellular fluid volumes. D5W is avoided
in clients at risk for increased intracranial pressure (IICP) because it can increase
cerebral edema.
Hypotonic solutions are used to provide free water and treat cellular dehydration.
These solutions promote waste elimination by the kidneys. Do not administer to
clients at risk for IICP or third-space fluid shift.
Hypertonic solutions draw fluid out of the intracellular and interstitial compartments
into the vascular compartment, expanding vascular volume. Do not administer to
clients with kidney or heart disease or clients who are dehydrated. Watch for signs of
hypervolemia.
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1455
Basilic vein
Cephalic vein
Dorsal venous
network
Dorsal
metacarpal veins
B
Cephalic vein
Median
cubital
vein
Accessory
cephalic vein
Cephalic vein
Radial vein
Medial
antebrachial
vein
Basilic vein
Insertion site
for PICC
Basilic vein
A
Figure 52-16 Commonly used venipuncture sites of the A, arm;
B, hand. A also shows the site used for a peripherally inserted central
catheter (PICC).
after trauma or surgery. They also may be used to replace fluid
and electrolytes for clients with continuing losses, for example,
because of gastric suction or wound drainage.
Lactated Ringers solution is an alkalinizing solution that
may be given to treat metabolic acidosis. Acidifying solutions,
in contrast, are administered to counteract metabolic alkalosis.
Examples of acidifying solutions are 5% dextrose in 0.45%
sodium chloride and 0.9% sodium chloride solution.
Volume expanders are used to increase the blood volume fol-
lowing severe loss of blood (e.g., from hemorrhage) or loss of
plasma (e.g., from severe burns, which draw large amounts of
plasma from the bloodstream to the burn site). Examples of ex-
panders are dextran, plasma, and albumin.
VENIPUNCTURE SITES. The site chosen for venipuncture
varies with the clients age, the length of time the infusion is
to run, the type of solution used, and the condition of veins.
For adults, veins in the hand and arm are commonly used; for
infants, veins in the scalp and dorsal foot veins are often used.
Larger veins are preferred for infusions that need to be given
rapidly and for solutions that could be irritating (e.g., certain
medications).
The metacarpal, basilic, and cephalic veins are commonly
used for intermittent or continuous infusions (Figure 52-16
,
B). The ulna and radius act as natural splints at these sites, and
the client has greater freedom of arm movements for activities
such as eating. Although the basilic and median cubital veins in
the antecubital space are convenient sites for venipuncture, they
are usually used for blood draws, bolus injections of medica-
tion, and insertion sites for a peripherally inserted central
catheter line (see Figure 52-16 , A). See Practice Guidelines for
vein selection and general tips for easier IV starts.
When long-term IV therapy or parenteral nutrition is antici-
pated or the client is receiving IV medications that are damag-
ing to vessels (e.g., chemotherapy), a central venous catheter
may be inserted. Central venous catheters usually are inserted
into the subclavian or jugular vein, with the distal tip of the
catheter resting in the superior vena cava just above the right
atrium (Figure 52-17
). They may be inserted at the clients
bedside or, for longer term access, surgically inserted. Subcla-
vian central venous catheters permit freedom of movement for
ambulation; however, there is greater risk of complications, in-
cluding hemothorax or pneumothorax, cardiac perforation,
thrombosis, and infection. Assess the client closely for manifes-
tations such as shortness of breath, chest pain, cough, hypoten-
sion, tachycardia, and anxiety after the insertion procedure.
With a peripherally inserted central venous catheter (PICC),
the catheter is inserted in the basilic or cephalic vein just above
or below the antecubital space of the right arm. The tip of the
catheter rests in the superior vena cava. The risk of pneumotho-
rax is eliminated with PICC. These catheters frequently are used
for long-term intravenous access when the client will be man-
aging IV therapy at home.
Implantable venous access devices or ports (Figures 52-18
and 52-19 on page 1458) are used for clients with chronic ill-
ness who require long-term IV therapy (e.g., intermittent med-
ications such as chemotherapy, total parenteral nutrition, and
PRACTICE GUIDELINES Vein Selection
Use distal veins of the arm first.
Use the clients nondominant arm whenever possible.
Select a vein that is
a. Easily palpated and feels soft and full.
b. Naturally splinted by bone.
c. Large enough to allow adequate circulation around the
catheter.
Avoid using veins that are
a. In areas of flexion (e.g., the antecubital fossa).
b. Highly visible, because they tend to roll away from the
needle.
c. Damaged by previous use, phlebitis, infiltration, or sclerosis.
d. Continually distended with blood, or knotted or tortuous.
e. In a surgically compromised or injured extremity (e.g., fol-
lowing a mastectomy), because of possible impaired cir-
culation and discomfort for the client.
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1456
frequent blood samples). The device is designed to provide re-
peated access to the central venous system, avoiding the trauma
and complications of multiple venipunctures. Using local anes-
thesia, implantable ports are surgically placed into a small sub-
cutaneous pocket under the skin, usually on the anterior chest
near the clavicle, and no part of the port is exposed. The distal
end of the catheter is placed in the subclavian or jugular vein.
There are different kinds of implantable venous access devices
and they may be tunneled or nontunneled (Rosenthal, 2005b).
Special precautions need to be taken with all central lines and
venous access ports to ensure asepsis and catheter patency.
Nursing care of clients with these devices is outlined in Practice
Guidelines on page 1459.
INTRAVENOUS EQUIPMENT. Because equipment varies ac-
cording to the manufacturer, the nurse must become familiar
with the equipment used in each particular agency.
Solution containers are available in various sizes (50, 100,
250, 500, or 1,000 mL); the smaller containers are often used to
administer medications. Most solutions are currently dispensed
in plastic bags (Figure 52-20 ). However, glass bottles may
need to be used if the administered medications are incompati-
ble with plastic. Glass bottles require an air vent so that air can
enter the bottle and replace the fluid that enters the clients vein.
Some have a tube inside the bottle that serves as a vent; other
containers without air vents require a vent on the administration
set. Air vents usually have filters to prevent contamination from
the air that enters the container. Air vents are not required for
plastic solution bags, because the bags collapse under atmos-
pheric pressure when the solution enters the vein.
It is essential that the solution be sterile and in good condi-
tion, that is, clear. Cloudiness, evidence that the container has
been opened previously, or leaks indicate possible contamina-
tion. Always check the expiration date on the label. Return any
PRACTICE GUIDELINES General Tips for Easier IV Starts
Review the clients medical history. In general, youll want to
avoid using an arm affected by hemiplegia or with a dialysis ac-
cess. Also avoid an arm on the same side as a mastectomy,
sites near infections or below previous infiltrations of extrava-
sations, and veins affected by phlebitis.
Put gravity to work. Dangle the clients arm over the side of the
bed to encourage dependent vein filling.
Make sure the client is comfortable. Pain and anxiety stimulate
the sympathetic nervous system and trigger vasoconstriction
and vasovagal reactions. Have the client void before you start
the IV line, make sure he or she is warm enough, and admin-
ister pain medication as ordered before the procedure. Help
the patient into a comfortable prone or semi-Fowler position
for the IV insertion.
Warmth encourages vasodilation. Apply warm compresses to
the site for 10 to 15 minutes before you attempt venipuncture.
Unless contraindicated, the client could take a hot shower or
drink warm fluids before IV insertion.
Avoid hand veins. Because of the risk of nerve injuries, hand
veins should be a last choice, especially in older clients whose
skin is very thin.
Choose the right device for the ordered therapy. If the ordered
IV medication is irritating to veins and therapy is expected to
last more than a few days, consult with the IV nurse or medical
team to determine whether the client is a candidate for a mid-
line catheter, a peripherally inserted central catheter, or another
type of central venous access device.
Use the smallest gauge cannula that will accommodate the
therapy and allow good venous flow around the catheter tip.
For example, for routine hydration or intermittent therapies,
use 22- to 27-gauge catheters; for transfusion therapies, 20- to
24-gauge; and for therapy for neonates or clients with very
small, fragile veins, 24- to 27-gauge.
Use good body mechanics. Raise the bed or stretcher to a
comfortable working height. Sit, when possible, and keep all
equipment within reach. Stabilize the clients hand or arm with
your nondominant arm, tucking it under your forearm if neces-
sary to prevent a moving target.
Display confidence in your own abilities. When you approach
the client, dont say, Im here to try to start your IV line. In-
stead, confidently state, Im here to insert your IV line.
If you miss, offer an honest explanation in a matter-of-fact and
friendly manner. Think about what you can do to improve your
next attempt, and explain what youll do differently (if any-
thing). Most important, limit your attempts to two. If youre not
successful after two tries, ask another nurse or an anesthesia
provider to try again a little later.
Note: From Tailor Your I.V. Insertion Techniques for Special Populations, by
K. Rosenthal, 2005a, Nursing, 35(5), 39. Copyright 2005 Lippincott, Williams &
Wilkins. Reprinted with permission.
Subclavian vein
Catheter
Superior vena cava
A
Figure 52-17 Central venous lines with A, subclavian vein insertion,
and B, left jugular insertion.
Catheter
B
Internal jugular
vein
Subclavian vein
Superior
vena cava
koz74686_ch52.qxd 11/13/06 4:49 PM Page 1457
questionable or contaminated solutions to the pharmacy or IV
therapy department.
Infusion sets usually include an insertion spike, a drip cham-
ber, a roller valve or screw clamp, tubing with secondary ports,
and a protective cap over the needle adapter (Figure 52-21 ).
The insertion spike is kept sterile and inserted into the solution
container when the equipment is set up and ready to start. The
drip chamber permits a predictable amount of fluid to be deliv-
ered. A commonly used drip chamber is the 10 to 20 drops,
which delivers macrodrip per milliliter of solution. This infor-
Figure 52-19 An implantable venous access device (right) and a
Huber needle with extension tubing.
Catheter
Lock
Self-sealing septum
A
Figure 52-18 An implantable venous access device: A, components;
B, the device in place.
Skin
Catheter
Fluid flow
Suture
B
Figure 52-20 A plastic intravenous fluid container.
Protector cap
for insertion spike
Spike connector
for fluid container
Connector to
IV catheter
Drip chamber
Clamp
Clamp
Secondary
port
Secondary
port
Figure 52-21 A standard IV administration set.
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1458
mation is found on the package. There are also 60 drops sets,
which deliver microdrip per milliliter of solution. The roller
valve or screw clamp, which compresses the lumen of the tub-
ing, controls the rate of the flow. The protective cap over the nee-
dle adapter maintains the sterility of the end of the tubing so that
it can be attached to a sterile needle inserted in the clients vein.
Most infusion sets include one or more injection ports for ad-
ministering IV medications or secondary infusions. Needleless
systems are increasingly used because they reduce the risk of
needlestick injury and contamination of the intravenous line.
There are various types of needleless systems available, includ-
ing two-piece prepierced septum and blunt cannula devices,
Luer-activated devices, and three-way pressure-activated safety
valves (Rosenthal, 2003). With each of these needleless sys-
tems, a blunt cannula is inserted into a special injection port or
adapter on the IV tubing to administer medications or second-
ary infusions (Figure 52-22 ). Many infusion sets include an
in-line filter to trap air, particulate matter, and microbes. Aspe-
cial infusion set may be required if the IV flow rate will be reg-
ulated by an infusion pump.
Catheters and needles are commonly used for intravenous
infusions. Over-the-needle catheters, also known as angio-
caths, are commonly used for adult clients. The plastic
catheter fits over a needle used to pierce the skin and vein wall
(Figure 52-23 ). Once inserted into the vein, the needle is
withdrawn and discarded, leaving the catheter in place. IV
catheters allow the client more mobility and rarely infiltrate,
that is, become dislodged from the vein and allow fluid to flow
into interstitial spaces.
Safety devices on IVcatheters are now common. With the orig-
inal over-the-needle catheters, the sharp stylet remained exposed
until placed in a sharps container. This resulted in needlestick in-
juries to nurses. The 2000 Needlestick Safety and Prevention Act
requires the use of needle saftey devices to prevent exposure to
PRACTICE GUIDELINES Caring for Clients with a Venous Access Device
On insertion, document the date; the site; the brand, gauge,
and catheter length; the location of the catheter tip (verified by
x-ray); the length of the external segment; and client teaching.
Do not use the access device until correct placement has been
verified by x-ray.
SITE CARE
Use strict aseptic technique when caring for central lines and
long-term venous access devices.
The frequency of dressing changes may vary from every 3 to 7
days, depending on the site. Dressings also should be changed
when loose or soiled.
Assess the site for any redness, swelling, tenderness, or
drainage. Compare the length of the external portion of the
catheter with its documented length to assess for possible dis-
placement. Obtain a chest x-ray to determine the catheter tips
position if in doubt. Report and document any position
changes or signs of infection.
Follow agency protocol for cleaning solutions and types of
dressings. Isopropyl alcohol or a combination of alcohol and
acetone followed by povidone-iodine are commonly used to
clean the port site.
Before accessing the port, clean an area 2 inches in diameter
around the site with an alcohol-acetone solution on a sterile
cotton swab. Start at the center of the port site, moving out-
ward with a firm, circular motion. Follow with povidone-iodine
solution. Allow the site to air dry.
Secure the catheter, and cover the entry site and external por-
tion of the catheter with an occlusive dressing.
Provide routine care of the incision site for the implant device
until it is healed. Once it heals, no care is necessary when the
port is idle.
CATHETER CARE AND FLUSHING
Change the catheter cap as indicated by protocol, usually every
3 to 7 days.
Flush the port with normal saline, a heparin flush solution (10
units/mL or 100 units/mL), or as agency protocol recom-
mends for the specific type of port being used. After infusing
medications or solutions, again flush the port with saline be-
fore using heparinized saline.
Using a 10-mL syringe, flush the catheter with a solution of 10
units of heparin after each use. The frequency of flushes be-
tween uses may vary from every 12 hours to once a week or
less, depending on the type of catheter.
Remember to flush all lumens for multiple-lumen catheters.
Use a specially designed needle to access an implanted port.
A needle with a 90-degree angle is generally used for infusions
because it is easier to stabilize and more comfortable for the
client. Stabilizing the port between the thumb and index finger
of the nondominant hand, insert the needle through the cen-
ter of the port until the resistance of the platform is felt.
To remove the needle after a treatment, again stabilize the port
and use even pressure to withdraw the needle. Maintain posi-
tive pressure by withdrawing the needle as the last milliliter of
flush solution is being instilled.
Flush idle implanted ports with heparinized saline in accor-
dance with agency protocol or at least every 8 weeks.
TEACHING
Provide clients with the following instructions:
Do not allow anyone to take a blood pressure on the arm in
which a PICC line is inserted.
Wear a medic-alert tag or bracelet if the device is to be in place
for a long period.
For a PICC, you do not need to restrict activities, except do not
immerse the arm in water. Showering is allowed if the site and
catheter are covered by an occlusive dressing.
For an implanted venous port there are no activity restrictions,
but remember that the port or catheter tip can become dis-
lodged. Signs of a dislodged catheter tip include pain in the
neck or ear on the affected side, swishing or gurgling sounds,
or palpitations. Free movement of the port, swelling, or diffi-
culty accessing the port may indicate port dislodgment. Notify
the primary care provider should any of these occur or if symp-
toms of infection develop.
Note: From Getting a Line on Central Vascular Access Devices, by S. Masoorli &
T. Angeles, 2002, Nursing, 32(4), pp. 3643. Copyright 2005 Lippincott,
Williams & Wilkins. Reprinted with permission.
koz74686_ch52.qxd 11/13/06 4:49 PM Page 1459
bloodborne pathogens (Wilburn, 2004). The safety devices for IV
catheters vary. They can be either an active safety device which re-
quires activation by the nurse or a passive safety device where the
safety feature is automatically activated after the sytlet is removed
from the catheter.
Butterfly, or wing-tipped, needles with plastic flaps attached to
the shaft are sometimes used (Figure 52-24 ). The flaps are held
tightly together to hold the needle securely during insertion; after
insertion, they are flattened against the skin and secured with tape.
IV poles are used to hang the solution container. Some
poles are attached to hospital beds; others stand on the floor
Figure 52-22 Cannulae used to connect the tubing of additive sets to primary infusions: A, threaded-lock cannula; B, lever-lock cannula.
(Photographs reprinted courtesy of (BD) Becton, Dickinson and Company and courtesy of Baxter Healthcare Corporation. All rights reserved.)
A B
Introducer
needle Cannula
Translucent
catheter hub
Preview
chamber
Flashback
chamber
Filter
vent
Luer lock
tabs
Finger
guard
Needle bevel
position indicator
Short bevel
introducer
needle
Needle
heel
Tapered
catheter tip
Figure 52-23 Schematic of an over-the-needle catheter.
Cap for needle
Plastic
adapter
Tubing
Stem
Wings
Figure 52-24 Schematic of a butterfly needle with adapter.
or hang from the ceiling. In the home, plant hangers or robe
hooks (even kitchen cabinet knobs or an S-hook over the top
of a door) may be used to hang solution containers. The
height of most poles is adjustable. The higher the solution
container, the greater the force of the solution as it enters the
client and the faster the rate of flow.
STARTING AN INTRAVENOUS INFUSION. Although the pri-
mary care provider is responsible for ordering IV therapy for
clients, nurses initiate, monitor, and maintain the prescribed
IV infusion. This is true not only in hospitals and long-term
care facilities but increasingly in community-based settings
such as clinics and clients homes.
Before startinganinfusion, the nurse determines the following:
The type and amount of solution to be infused
The exact amount (dose) of any medications to be added to a
compatible solution
The rate of flow or the time over which the infusion is to be
completed
If solutions are prepared by the pharmacy or another depart-
ment, the nurse must verify that the solution supplied exactly
matches that which the primary care provider ordered.
Understanding the purpose for the infusion is as important
as assessing the client. For example, the nurse may question
an order for 5% dextrose in water at 150 mL/h if the client
has peripheral edema and other signs of fluid overload.
To perform venipuncture and start an intravenous infusion,
see Skill 52-1.
M
e
d
i
a
L
i
n
k

A
p
p
l
y
i
n
g

a

C
e
n
t
r
a
l

V
e
n
o
u
s

L
i
n
e

A
n
i
m
a
t
i
o
n
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1460
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STARTING AN INTRAVENOUS INFUSION
Before preparing the infusion, the nurse first verifies the primary
care providers order indicating the type of solution, the amount to
be administered, the rate of flow of the infusion, and any client
allergies (e.g., to tape or povidone-iodine).
PURPOSES
To supply fluid when clients are unable to take in an adequate
volume of fluids by mouth
To provide salts and other electrolytes needed to maintain elec-
trolyte balance
To provide glucose (dextrose), the main fuel for metabolism
To provide water-soluble vitamins and medications
To establish a lifeline for rapidly needed medications
ASSESSMENT
Assess the following:
Vital signs (pulse, respiratory rate, and blood pressure) for base-
line data
Skin turgor
Allergy to latex (e.g., tourniquet), tape, or iodine
Bleeding tendencies
Disease or injury to extremities
Status of veins to determine appropriate venipuncture site
PLANNING
Prior to initiating the IV infusion, consider how long the client is likely
to have the IV, what kinds of fluids will be infused, and what medica-
tions the client will be receiving or is likely to receive. These factors
may affect the choice of vein and catheter size.
Delegation
This procedure is done by a registered nurse and, in many states,
by a licensed pratical nurse or licensed vocational nurse. Check
the states nurse practice act. Due to the use of sterile technique,
intravenous infusion therapy is not delegated to unlicensed as-
sistive personnel (UAP). UAP may care for clients receiving IV
therapy, and the nurse must ensure that the UAP knows how to
perform routine tasks such as bathing and positioning without
disturbing the IV. The UAP should also know what complications
or adverse signs, such as leakage, should be reported to the
nurse. In some states a licensed vocational nurse with special IV
therapy training may start intravenous infusions.
Equipment
Infusion set
Sterile parenteral solution
IV pole
Adhesive or nonallergenic tape
Clean gloves
Tourniquet
Antiseptic swabs
Antiseptic ointment (check agency policy)
Intravenous catheter; see Variation at the end of this procedure
for a butterfly (winged-tip) needle
Sterile gauze dressing or transparent occlusive dressing
Arm splint, if required
Towel or pad
Electronic infusion device or pump (The nurse decides what de-
vice is needed as appropriate to the clients condition.)
IMPLEMENTATION
Preparation
1. Prepare the client.
Prior to performing the procedure, introduce self and verify
the clients identity using agency protocol. Explain the proce-
dure to the client. A venipuncture can cause discomfort for
a few seconds, but there should be no discomfort while the
solution is flowing. Use a doll to demonstrate for children,
and explain the procedure to the parents. Clients often want
to know how long the process will last. The primary care
providers order may specify the length of time of the infu-
sion, for example, 3,000 mL over 24 hours.
Unless initiating IV therapy is urgent, provide any scheduled
care before establishing the infusion to minimize movement
of the affected limb during the procedure. Moving the limb af-
ter the infusion has been established could dislodge the
catheter.
Make sure that the clients clothing or gown can be removed
over the IV apparatus if necessary. Some agencies provide
special gowns that open over the shoulder and down the
sleeve for easy removal.
Performance
Perform hand hygiene.
1. Open and prepare the infusion set.
Remove tubing from the container and straighten it out.
Slide the tubing clamp along the tubing until it is just below
the drip chamber to facilitate its access.
Close the clamp.
Leave the ends of the tubing covered with the plastic caps
until the infusion is started. Rationale: This will maintain the
sterility of the ends of the tubing.
2. Spike the solution container.
Remove the protective cover from the entry site of the bag.
Remove the cap from the spike and insert the spike into the
insertion site of the bag or bottle. Follow the manufac-
turers instructions.
3. Apply a medication label to the solution container if a medica-
tion is added.
In many agencies, medications and labels are applied in the
pharmacy; if they are not, apply the label upside down on
the container. Rationale: The label is applied upside down
so it can be read easily when the container is hanging up.
koz74686_ch52.qxd 11/8/06 2:07 PM Page 1461
STARTING AN INTRAVENOUS INFUSION continued
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4. Apply a timing label on the solution container.
The timing label may be applied at the time the infusion is
started. Follow agency practice. See later discussion of regu-
lating infusion flow rates and Figure 52-26.
5. Hang the solution container on the pole.
Adjust the pole so that the container is suspended about
1 m (3 ft) above the clients head. Rationale: This height is
needed to enable gravity to overcome venous pressure and
facilitate flow of the solution into the vein.
6. Partially fill the drip chamber with solution.
Squeeze the chamber gently until it is half full of solution.
7. Prime the tubing.
Remove the protective cap and hold the tubing over a con-
tainer. Maintain the sterility of the end of the tubing and the
cap.
Release the clamp and let the fluid run through the tubing un-
til all bubbles are removed. Tap the tubing if necessary with
your fingers to help the bubbles move. Rationale: The tub-
ing is primed to prevent the introduction of air into the client.
Air bubbles smaller than 0.5 mL usually do not cause problems in
peripheral lines.
Reclamp the tubing and replace the tubing cap, maintaining
sterile technique.
For caps with air vents, do not remove the cap when prim-
ing this tubing. The flow of solution through the tubing will
cease when the cap is moist with one drop of solution.
If an infusion control pump, electronic device, or controller is
being used, follow the manufacturers directions for inserting
the tubing and setting the infusion rate.
8. Perform hand hygiene again just prior to client contact.
9. Select the venipuncture site.
Use the clients nondominant arm, unless contraindicated
(e.g., mastectomy, fistula for dialysis). Identify possible
venipuncture sites by looking for veins that are relatively
straight, not sclerotic or tortuous, and avoid venous valves.
The vein should be palpable, but may not be visible, espe-
cially in clients with dark skin. Consider the catheter length;
look for a site sufficiently distal to the wrist or elbow that the
tip of the catheter will not be at a point of flexion. Rationale:
Sclerotic veins may make initiating and maintaining the IV
difficult. Joint flexion increases the risk of irritation of vein
walls by the catheter.
Check agency protocol about shaving if the site is very
hairy. Shaving is not usually recommended because of the
potential for microabrasions which can increase the risk
of infection.
Place a towel or bed protector under the extremity to protect
linens (or furniture if in the home).
10. Dilate the vein.
Place the extremity in a dependent position (lower than the
clients heart). Rationale: Gravity slows venous return and
distends the veins. Distending the veins makes it easier to
insert the needle properly.
Apply a tourniquet firmly 15 to 20 cm (6 to 8 in.) above the
venipuncture site. Explain that the tourniquet will feel
tight. Rationale: The tourniquet must be tight enough to ob-
struct venous flow but not so tight that it occludes arterial
flow. Obstructing arterial flow inhibits venous filling. If a ra-
dial pulse can be palpated, the arterial flow is not obstructed.
Use the tourniquet on only one client. This avoids cross-
contamination to other clients.
Inserting the spike.
Photographer: Elena Dorfman
Pull this end
to untie
A
B
Applying a tourniquet.
Squeezing the drip chamber.
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Holding the over-the-needle catheter at a 15- to 30-degree
angle with bevel up, insert the catheter through the skin and
into the vein. Sudden lack of resistance is felt as the needle
enters the vein. Jabbing, stabbing, or quick thrusting should
be avoided because it may cause rupture of delicate veins
(Phillips, 2005).
Once blood appears in the lumen of the needle or you feel
the lack of resistance, lower the angle of the catheter until it
is almost parallel with the skin, and advance the needle and
catheter approximately 0.5 to 1 cm (about 1/4 in.) farther.
Holding the needle portion steady, advance the catheter un-
til the hub is at the venipuncture site. The exact technique
depends on the type of device used. Rationale: The
catheter is advanced to ensure that it, and not just the metal
needle, is in the vein. The exact technique depends on the
type of catheter used.
Release the tourniquet.
Put pressure on the vein proximal to the catheter to elimi-
nate or reduce blood oozing out of the catheter. Stabilize the
hub with thumb and index finger of the nondominant hand.
Remove the protective cap from the distal end of the tubing
and hold it ready to attach to the catheter, maintaining the
sterility of the end.
Carefully remove the needle, engage the needle safety device,
and attach the end of the infusion tubing to the catheter hub.
Initiate the infusion.
13. Tape the catheter.
Tape the catheter by the U method or according to the
manufacturers instructions. Using three strips of adhesive
tape, each about 7.5 cm (3 in.) long:
a. Place one strip, sticky side up, under the catheters hub.
b. Fold each end over so that the sticky sides are against the
skin.
c. Place the second strip, sticky side down, over the catheter
hub.
d. Place the third strip, sticky side down, over the tubing hub.
14. Dress and label the venipuncture site and tubing according to
agency policy.
Unless there is an allergy, a sterile transparent occlusive
dressing is applied. This permits assessment of the site
If the vein is not sufficiently dilated:
a. Massage or stroke the vein distal to the site and in the di-
rection of venous flow toward the heart. Rationale: This
action helps fill the vein.
b. Encourage the client to clench and unclench the fist.
Rationale: Contracting the muscles compresses the dis-
tal veins, forcing blood along the veins and distending
them.
c. Lightly tap the vein with your fingertips. Rationale:
Tapping may distend the vein.
If the preceding steps fail to distend the vein so that it is pal-
pable, remove the tourniquet and wrap the extremity in a
warm, moist towel for 10 to 15 minutes. Rationale: Heat di-
lates superficial blood vessels, causing them to fill. Then re-
peat step 10.
11. Put on clean gloves and clean the venipuncture site.
Rationale: Gloves protect the nurse from contamination by
the clients blood.
Clean the skin at the site of entry with a topical antiseptic swab
(e.g., 2% chlorhexidine, or alcohol). Some institutions may
use an anti-infective solution such as povidone-iodine (check
agency protocol). Check for allergies to iodine or shellfish be-
fore cleansing skin with Betadine or iodine products.
Use a circular motion, moving from the center outward for
several inches. Rationale: This motion carries microorgan-
isms away from the site of entry.
Permit the solution to dry on the skin. Povidone-iodine should
be in contact with the skin for 1 minute to be effective.
12. Insert the catheter and initiate the infusion.
If desired and permitted by policy, inject 0.05 mL of 1% li-
docaine intradermally over the site where you plan to insert
the IV needle. Allow 5 to 10 seconds for the anesthetic to
take effect. Transdermal analgesic creams (e.g., ELA-Max,
EMLA) may also be used, depending on policy. Allow 30
minutes for the transdermal analgesic to take effect.
Use the nondominant hand to pull the skin taut below the
entry site. Rationale: This stabilizes the vein and makes the
skin taut for needle entry. It can also make initial tissue pen-
etration less painful.
Taping an intravenous catheter by the U method.
Cover insertion site with transparent dressing.
(Patrick Watson)
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without disturbing the dressing. This type of dressing can be
left on for 72 hours, then changed.
Discard the tourniquet. Remove soiled gloves and discard
appropriately.
Loop the tubing and secure it with tape. Rationale: Looping
and securing the tubing prevent the weight of the tubing or
any movement from pulling on the needle or catheter.
Label the dressing with the date and time of insertion, type,
gauge of catheter used, and your initials.
15. Ensure appropriate infusion flow.

Apply a padded arm board to splint the joint, as needed.
Adjust the infusion rate of flow according to the order.
16. Label the IV tubing.
Label the tubing with the date and time of attachment and
your initials.
This labeling may also be done when the in-

fusion is started. Rationale: The tubing is labeled to ensure
that it is changed at regular intervals (i.e., every 24 to 96
hours according to agency policy).
17. Document relevant data, including assessments.
Record the start of the infusion on the clients chart. Some
agencies provide a special form for this purpose. Include the
date and time of the venipuncture; amount and type of solu-
tion used, including any additives (e.g., kind and amount of
medications); container number; flow rate; type, length, and
gauge of the needle or catheter; venipuncture site, how many
attempts were made, and location of each attempt; the type
of dressing applied; and the clients general response.
SAMPLE DOCUMENTATION
1/15/2008 0600 Inserted 20 gauge angiocath in (L) forearm
on first attempt. IV infusing at 125 mL/hour. Explained reason
for IV. Stated understanding.
______________
A. Luis, RN
VARIATION: INSERTING A BUTTERFLY
(WINGED-TIP) NEEDLE
Hold the needle, pointed in the direction of the blood flow, at a 30-
degree angle, with the bevel up, and pierce the skin beside the vein
about 1 cm (1/2 in.) below the site planned for piercing the vein.
Once the needle is through the skin, lower the needle so that it
is almost parallel with the skin. Rationale: Lowering the needle
reduces the chances of puncturing both sides of the vein.
Follow the course of the vein, and pierce one side of the vein. Sud-
den lack of resistance can be felt as blood enters the needle.
When blood flows back into the needle tubing, insert the nee-
dle to its hub.
Release the tourniquet, attach the infusion, and initiate flow as
quickly as possible. Rationale: Attaching the tubing quickly pre-
vents blood from clotting and obstructing the needle.
Secure the butterfly needle by taping it securely by the crisscross
(chevron) method.
Place a small gauze square under the

needle, if required. Rationale: The gauze keeps the needle in
position in the vein.
Label IV site with date, time, size of catheter, and initials.
(Patrick Watson)
I.V. SET__ HRS.ONLY
START DATE________HR._____
DISCARD DATE______HR._____
R.N. INITIAL_________________
72
9/11
9/14
0800
0800
LA
Tubing labeled with date, time of attachment, and nurses initials.
Also shown is a preprinted label.
Needle in vein
Tape
Tubing
Taping the butterfly needle by the chevron method.
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EVALUATION
Evaluate the following:
Skin status at IV site (warm temperature and absence of pain,
redness, and swelling)
Status of dressing
IV flow rate consistent with that ordered
Ability to perform self-care activities; understanding of any mo-
bility limitations
Vital signs compared to baseline level
REGULATING AND MONITORING INTRAVENOUS INFUSIONS.
Orders for IVinfusions may take several forms: 3,000 mLover
24 hours; 1,000 mL every 8 hours 3 bags; 125 mL/h un-
til oral intake is adequate. The nurse initiating the IVcalculates
the correct flow rate, regulates the infusion, and monitors the
clients responses. Unless an infusion control device is used, the
nurse manually regulates the drops per minute of flow using the
roller clamp to ensure that the prescribed amount of solution
will be infused in the correct time span. If the flow is incorrect,
problems such as hypervolemia, hypovolemia, or inadequate
medication administration can result.
The number of drops delivered per milliliter of solution
varies with different brands and types of infusion sets. This
rate, called the drip factor (sometimes called the drop factor),
generally is printed on the package of the infusion set. Macro-
drops commonly have drop factors of 10, 12, 15, or 20
drops/mL; the drop factor for microdrip is always 60
drops/mL (Figure 52-25 ).
To calculate flow rates, the nurse must know the volume of
fluid to be infused and the specific time for the infusion. Two
commonly used methods of indicating flow rates are designat-
ing the number of milliliters to be administered in 1 hour (mL/h)
and the number of drops to be given in 1 minute (gtt/min). Be-
cause l milliliter of fluid displaces 1 cubic centimeter of space,
the volume to be infused in the first method may also be desig-
nated as cubic centimeters per hour (cc/h).
Milliliters per Hour. Hourly rates of infusion can be calculated
by dividing the total infusion volume by the total infusion time
Figure 52-25

Infusion set spikes and drip chambers: nonvented
macrodrip, vented macrodrip, nonvented microdrip.
in hours. For example, if 3,000 mL is infused in 24 hours, the
number of milliliters per hour is
3,000 mL (total infusion volume)
125 mL/h
24 h (total infusion time)
Nurses need to check infusions at least every hour to ensure that
the indicated milliliters per hour have infused and that IVpatency
is maintained. A strip of adhesive marking the exact time and/or
amount to be infused may be taped to the solution container. Some
agencies make premarked labels available (Figure 52-26 ).
Drops per Minute. The nurse initiating and monitoring an in-
fusion must regulate the drops per minute to ensure that the pre-
scribed amount of solution will infuse. Drops per minute are
calculated by the following formula:
Drops per minute
Total infusion volume drop factor
Total time of infusion in minutes
If the requirements are 1,000 mL in 8 hours and the drip factor
is 20 drops/mL, the drops per minute should be
1,000 mL 20
8 60 min (480 min)
41 drops/min
Approximating this rate as 40 drops/min, the nurse regulates the
drops per minute by tightening or releasing the IVtubing clamp
and counting the drops for 15 seconds, then multiplying that
number by 4 (e.g., 10 drops/15 sec).
Anumber of factors influence flow rate (see Box 528).
Figure 52-26 Timing label on an intravenous container. The first time
marked (0900 hours) would be correct for a bag hung at 0800 hours
with a rate of 100 mL per hour.
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BOX 528 Factors Influencing Flow Rates
The position of the forearm. Sometimes a change in the position
of the clients arm decreases flow. Slight pronation, supination, ex-
tension, or elevation of the forearm on a pillow can increase flow.
The position and patency of the tubing. Tubing can be obstructed
by the clients weight, a kink, or a clamp closed too tightly. The
flow rate also diminishes when part of the tubing dangles below
the puncture site.
The height of the infusion bottle. Elevating the height of the infusion
bottle a few inches can speed the flow by creating more pressure.
Possible infiltration or fluid leakage. Swelling, a feeling of coldness,
and tenderness at the venipuncture site may indicate infiltration.
Relationship of the size of the angiocath to the vein. A catheter
that is too large may impede the infusion flow.
Figure 52-27

The Dial-A-Flo in-line device.
Figure 52-28 An intravenous infusion pump.
Photographer: Jenny Thomas
Figure 52-29 Programmable infusion pumps.
(Courtesy of ALARIS Medical Systems, Inc., San Diego, California.)
DEVICES TO CONTROL INFUSIONS. A number of devices are
used to control the rate of an infusion. Electronic infusion devices
(EIDs) regulate the infusion rate at preset limits. They also have
an alarm that is triggered when the solution in the IV bag is low,
when there is air in the tubing, or when the tubing is not high
enough. The Dial-A-Flo in-line device (Figure 52-27 ) is a reg-
ulator that controls the amount of fluid to be administered. Hos-
pitals may stock the Dial-A-Flo for use in situations where a
pump is not required, but prevention of fluid overload is impor-
tant. It is preset at the volume to be infused and can be attached at
the time the infusion is set up or when the tubing is changed. An-
other variation is a volume-control set, or Volutrol, which is used
if the volume of fluid administered is to be carefully controlled.
The set, which holds a maximum of 100 mL of solution, is at-
tached below the solution container, and the drip chamber is
placed below the set. Volume-control sets are frequently used in
pediatric settings, where the volume administered is critical.
CLINICAL ALERT
A flow rate control device should be used when administering IV fluid to
elderly or pediatric clients. Both of these age groups are especially at risk
for complications of fluid overload, which can occur with rapid infusion
of IV fluids.
An infusion pump (Figures 52-28 and 52-29 ) delivers
fluids intravenously by exerting positive pressure on the tubing
or on the fluid. In situations where the fluid flow is unrestricted,
the pump pressure is comparable to that of gravity flow. How-
ever, if restrictions develop (increased venous resistance), the
pump can maintain the fluid flow by increasing the pressure ap-
plied to the fluid.
A controller, by contrast, operates solely by gravitational
force. The delivery pressure depends on the height of the con-
tainer in relation to the venipuncture site. The container must be
at least 76 cm (30 in.) above the venipuncture site for a con-
troller to work. A controller does not have the ability to add
pressure to the line and to overcome resistances to fluid flow.
Skill 52-2 outlines the steps involved in monitoring an intra-
venous infusion.
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MONITORING AN INTRAVENOUS INFUSION
PURPOSES
To maintain the prescribed flow rate
To prevent complications associated with IV therapy
ASSESSMENT
Appearance of infusion site; patency of system
Type of fluid being infused and rate of flow
Response of the client
PLANNING
Review the type of equipment used outside the clients room. Read
all appropriate materials and confirm the type of tubing, controller, or
pump being used.
Delegation
This procedure should be done by the nurse because it is an im-
portant part of assessment and complications may occur.
IMPLEMENTATION
Preparation
1. Gather the pertinent data.
From the primary care providers order, determine the type
and sequence of solutions to be infused.
Determine the rate of flow and infusion schedule.
Performance
1. Ensure that the correct solution is being infused.
If the solution in incorrect, slow the rate of flow to a mini-
mum to maintain the patency of the catheter. Rationale:
Stopping the infusion may allow a thrombus to form in the
IV catheter. If this occurs, the catheter must be removed and
another venipuncture performed before the infusion can be
resumed.
Change the solution to the correct one. Document and re-
port the error according to agency protocol.
2. Observe the rate of flow every hour.
Compare the rate of flow regularly, for example, every hour,
against the infusion schedule. Rationale: Infusions that are
off schedule can be harmful to a client.
If the rate is too fast, slow it so that the infusion will be com-
pleted at the planned time. Rationale: Solution administered
too quickly may cause a significant increase in circulating
blood volume (which is about 6 L in an adult). Hypervolemia
may result in pulmonary edema and cardiac failure. Assess
the client for manifestations of hypervolemia and its compli-
cations, including dyspnea; rapid, labored breathing; cough;
crackles (rales) in the lung bases; tachycardia; and bounding
pulses.
If the rate is too slow, check agency practice. Some agencies
permit nursing personnel to adjust a rate of flow by a speci-
fied amount. Adjustments above this rate require a primary
care providers order. Rationale: Solution that is adminis-
tered too slowly can supply insufficient fluid, electrolytes, or
medication for a clients needs.
If the rate of flow is 150 mL/h or more, check the rate of flow
more frequently, for example, every 15 to 30 minutes.
3. Inspect the patency of the IV tubing and catheter.
Observe the position of the IV solution. If it is less than 1 m
(3 ft) above the IV site, readjust it to the correct height of the
pole. Rationale: If the IV bag/bottle is too low, the solution
may not flow into the vein because there is insufficient grav-
itational pressure to overcome the pressure of the blood
within the vein.
Observe the drip chamber. If it is less than half full, squeeze
the chamber to allow the correct amount of fluid to flow in.
Open the drip regulator and observe for a rapid flow of fluid
from the solution container into the drip chamber. Then
partially close the drip regulator to reestablish the pre-
scribed rate of flow. Rationale: Rapid flow of fluid into the
drip chamber indicates patency of the IV line. Closing the
drip regulator to the prescribed rate of flow prevents fluid
overload.
Inspect the tubing for pinches or kinks or obstructions to
flow. Arrange the tubing so that it is lightly coiled and under
no pressure. Sometimes the tubing becomes caught under
the clients body and the weight blocks the flow.
Observe the position of the tubing. If it is dangling below the
venipuncture, coil it carefully on the surface of the bed.
Rationale: The solution may not flow upward into the vein
against the force of gravity.
Lower the solution container below the level of the infusion
site and observe for a return flow of blood from the vein.
Rationale: A return flow of blood indicates that the needle
is patent and in the vein. Blood returns in this instance be-
cause venous pressure is greater than the fluid pressure in
the IV tubing. Absence of blood return may indicate that the
needle is no longer in the vein or that the tip of the catheter
is partially obstructed by a thrombus, the vein wall, or a
valve in the vein.
Determine whether the bevel of the catheter is blocked
against the wall of the vein. If it is blocked, pull back gently,
turn it slightly, or carefully raise or lower the angle of inser-
tion slightly, using a sterile gauze pad underneath to protect
the skin and change the position of the catheter bevel.
If there is leakage, locate the source. If the leak is at the
catheter connection, tighten the tubing into the catheter. If
the leak cannot be stopped, slow the infusion as much as
possible without stopping it, and replace the tubing with a
new sterile set. Estimate the amount of solution lost, if it was
substantial.
4. Inspect the insertion site for fluid infiltration.
When an IV needle becomes dislodged from the vein, fluid
flows into interstitial tissues, causing swelling. This is known
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as infiltration and is manifested by localized swelling, cool-
ness, pallor, and discomfort at the IV site.
If an infiltration is present, stop the infusion and remove the
catheter. Restart the infusion at another site.
Apply a warm compress to the site of the infiltration. Ration-
ale: Warmth promotes comfort and vasodilation, facilitating
absorption of the fluid from interstitial tissues.
5. If the infiltration involves a vesicant drug, it is called extravasa-
tion and other measures may be indicated. Extravasated vesi-
cant drugs can cause severe tissue injury or destruction. The
extravasation of a vesicant drug should be considered an emer-
gency (Hadaway, 2004).
Stop the infusion immediately. Disconnect the tubing as
close to the catheter hub as possible and attempt to aspirate
any drug remaining in the hub. If an injectable antidote is
available, the catheter should remain in place.
The primary care provider should be notified and if ordered,
the antidote administered.
The affected arm should be elevated and depending on the
drug, heat or cold therapy should be implemented.
6. If infiltration is not evident but the infusion is not flowing, de-
termine whether the needle is dislodged from the vein.
Gently pinch the IV tubing adjacent to the needle site. This
will cause blood to flow (flash back) into the tubing if the
needle is in the vein.
Use a sterile syringe of saline to withdraw fluid from the port
near the venipuncture site. If blood does not return, discon-
tinue the intravenous solution.
7. Inspect the insertion site for phlebitis (inflammation of a vein).
Inspect and palpate the site at least every 8 hours. Phlebitis
can occur as a result of injury to a vein, for example, because
of mechanical trauma or chemical irritation. Chemical injury
to a vein can occur from intravenous electrolytes (especially
potassium and magnesium) and medications. The clinical
signs are redness, warmth, and swelling at the intravenous
site and burning pain along the course of a vein.
If phlebitis is detected, discontinue the infusion, and apply
warm compresses to the venipuncture site. Do not use this
injured vein for further infusions.
8. Inspect the intravenous site for bleeding.
Oozing or bleeding into the surrounding tissues can occur
while the infusion is freely flowing but is more likely to occur
after the needle has been removed from the vein.
Observation of the venipuncture site is extremely important
for clients who bleed readily, such as those receiving antico-
agulants.
9. Teach the client ways to maintain the infusion system, for
example:
Avoid sudden twisting or turning movements of the arm with
the needle or catheter.
Avoid stretching or placing tension on the tubing.
Try to keep the tubing from dangling below the level of the
needle.
Notify a nurse if
a. The flow rate suddenly changes or the solution stops
dripping.
b. The solution container is nearly empty.
c. There is blood in the IV tubing.
d. Discomfort or swelling is experienced at the IV site.
10. Document all relevant information.
EVALUATION
Amount of fluid infused according to the schedule
Intactness of IV system
Appearance of IV site (e.g., dry, tissue infiltration, discomfort)
Urinary output compared to urinary intake
Tissue turgor; specific gravity of urine
Vital signs and lung sounds compared to baseline data
CHANGING INTRAVENOUS CONTAINERS, TUBING, AND
DRESSINGS. Intravenous solution containers are changed
when only a small amount of fluid remains in the neck of the
container and fluid still remains in the drip chamber. However,
all IV bags should be changed every 24 hours, regardless of
how much solution remains, to minimize the risk of contami-
nation. IV tubing is changed every 48 to 96 hours, depending
on agency protocol, as is the site dressing. Skill 52-3 provides
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CHANGING AN INTRAVENOUS CONTAINER, TUBING, AND DRESSING
PURPOSES
To maintain the flow of required fluids
To maintain sterility of the IV system and decrease the incidence
of phlebitis and infection
ASSESSMENT
Presence of fluid infiltration, bleeding, or phlebitis at IV site
Allergy to tape or iodine
Infusion rate and amount absorbed
Blockages in IV system
Appearance of the dressing for integrity, moisture, and need for
change
The date and the time of the previous dressing change
To maintain patency of the IV tubing
To prevent infection at the IV site and the introduction of mi-
croorganisms into the bloodstream
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CHANGING AN INTRAVENOUS CONTAINER, TUBING, AND DRESSING continued
Timing label
Sterile gauze square for positioning the needle
For the Dressing
Clean gloves
Sterile 2-in. 2-in. or 4-in. 4-in. gauze or transparent dressing
Adhesive remover
Chlorhexidine swabs
Alcohol swabs
Tape
Towel
PLANNING
Review primary care providers orders for changes in fluid administration.
Delegation
This procedure includes assessment of the IV site and should be
completed by a registered nurse. In many states, licensed voca-
tional nurses with IV certification may complete the procedure.
Equipment
Container with the correct kind and amount of sterile solution
Administration set, including sterile tubing and drip chamber
IMPLEMENTATION
Preparation
1. Obtain the correct solution container.
Read the label of the new container.
Verify that you have the correct solution, correct client, cor-
rect additives (if any), and correct dose (number of bags or
total volume ordered).
Performance
1. Perform hand hygiene.
2. Set up the intravenous equipment with the new container and
label all. See Skill 52-1, steps 1 to 8.
Apply a timing label to the container.
Prime the tubing.
Label the tubing as shown in Figure in Skill 52-1.
3. Prepare the IV needle or catheter, tape, and the dressing equip-
ment near the client.
Prepare strips of tape as needed for the type of needle or
catheter. For the butterfly needle, two or three strips of
1.25-cm (1/2-in.) tape are needed. For a catheter, three
strips of 1.25-cm (1/2-in.) tape are needed. These will be
used later to secure the needle or catheter without cover-
ing the insertion site.
Hang the pieces of tape from the edge of a table. Rationale:
This places the tape in readiness for use without disrupting
the adhesive. Ensure that the table is clean to avoid contam-
inating the tape.
Open all equipment: swabs, dressing and adhesive band-
age, and ointment. Rationale: This facilitates access to sup-
plies after gloves are donned.
Place a towel under the extremity. Rationale: This prevents
soiling of bed linens.
Apply clean gloves.
4. Remove the soiled dressing and all tape, except the tape hold-
ing the catheter or IV needle in place.
Remove tape and gauze from the old dressing one layer at
a time. Rationale: This prevents dislodgment of the catheter
or needle in case tubing becomes entangled between lay-
ers of dressing.
Remove adhesive dressings in the direction of the clients
hair growth when possible. Rationale: This minimizes dis-
comfort when adhesive is removed from the skin.
Discard the used dressing materials in the appropriate
container.
5. Assess the IV site.
Inspect the IV site for the presence of infiltration or inflam-
mation. Rationale: Inflammation or infiltration necessitates
removal of the IV needle or catheter to avoid further trauma
to the tissues.
Go to step 6, or discontinue and relocate the IV site if indi-
cated. See Skills 52-1 and 52-4.
6. Disconnect the used tubing.
Place a sterile swab under the hub of the catheter.
Rationale: This absorbs any leakage that might occur when
the tubing is disconnected.
Clamp the tubing. With the fourth or fifth finger of the non-
dominant hand, apply pressure to the vein above the end of
the catheter. Rationale: This helps prevent blood from com-
ing out of the needle during the change of tubing.
Holding the hub of the catheter with the thumb and index
finger of the nondominant hand, loosen the tubing with the
dominant hand, using a twisting, pulling motion. Rationale:
Holding the catheter firmly but gently maintains its position
in the vein.
Remove the used IV tubing.
Place the end of the tubing in the basin or other receptacle.
7. Connect the new tubing, and reestablish the infusion.
Continue to hold the catheter and grasp the new tubing with
the dominant hand.
Remove the protective tubing cap and, maintaining sterility,
insert the tubing end securely into the needle hub. Twist it to
secure it.
Open the clamp to start the solution flowing.
8. Remove the tape securing the needle or catheter.
When removing this tape and while cleaning the site, stabi-
lize the needle or catheter hub with one hand. Rationale:
This prevents inadvertent dislodgment of the needle or
catheter.
9. Clean the IV site.
Start with adhesive remover to remove adhesive residue.
Rationale: Removal of adhesive residue facilitates adher-
ence of the new dressing.
Then, using chlorhexidine swabs or alcohol swabs, clean the
site, beginning at the catheter or needle and cleaning out-
ward in a 2-in. diameter. Rationale: Cleaning in this man-
ner prevents contamination of the IV site from bacteria on
the peripheral skin areas. Antiseptics reduce the number of
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guidelines for changing an IV solution container, tubing, and
the IV site dressing.
When an IV infusion is no longer necessary to maintain the
clients fluid intake or to provide a route for medication admin-
istration, the infusion is either discontinued and the catheter re-
moved or the catheter is left in place and converted to a saline
or heparin lock. Guidelines for discontinuing an IV infusion or
converting the catheter to a lock are outlined in Skills 52-4 and
52-5, respectively.
CHANGING AN INTRAVENOUS CONTAINER, TUBING, AND DRESSING continued
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microorganisms present at the site, thus reducing the risk of
infection.
Follow agency protocol about cleaning procedures.
10. Retape the needle or catheter.
For a butterfly needle, apply strips of tape to the wings of
the butterfly using the crisscross (chevron) method
(Figure in Skill 52-1).
For a catheter; apply the tape using the U method
(Figure in Skill 52-1).
Apply a sterile transparent dressing over the site.
Remove gloves.
11. Label the dressing and secure IV tubing.
Place the date and time of the dressing change and your ini-
tials either on the label provided or directly over the top of
the dressing.
Secure IV tubing with additional tape as required.
12. Regulate the rate of flow of the solution according to the order
on the chart.
Record the change of the solution container, tubing, and/or
dressing in the appropriate place on the clients chart. Also
record the fluid intake according to agency practice. Record
the number of the container if the containers are numbered
at the agency. Also record your assessments.
EVALUATION
Status of IV site
Patency of IV system
Accuracy of flow
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DISCONTINUING AN INTRAVENOUS INFUSION
PURPOSE
To discontinue an intravenous infusion when the therapy is complete or when the IV site needs to be changed
ASSESSMENT
Appearance of the venipuncture site
Any bleeding from the infusion site
Amount of fluid infused
Appearance of IV catheter
PLANNING
Review the primary care providers orders.
Delegation
This procedure should be done by a registered nurse. In many
states, licensed vocational nurses may initiate and discontinue IV
therapy.
Equipment
Clean gloves
Dry or antiseptic-soaked swabs, according to agency practice
Small sterile dressing and tape
IMPLEMENTATION
Performance
1. Prepare the equipment.
Clamp the infusion tubing. Rationale: Clamping the tubing
prevents the fluid from flowing out of the needle onto the
client or bed.
Loosen the tape at the venipuncture site while holding the
needle firmly and applying countertraction to the skin.
Rationale: Movement of the needle can injure the vein and
cause discomfort to the client. Countertraction prevents
pulling the skin and causing discomfort.
Put on clean gloves and hold a sterile gauze above the
venipuncture site.
2. Withdraw the needle or catheter from the vein.
Withdraw the needle or catheter by pulling it out along the
line of the vein. Rationale: Pulling it out in line with the vein
avoids injury to the vein.
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DISCONTINUING AN INTRAVENOUS INFUSION continued
Immediately apply firm pressure to the site, using sterile
gauze, for 2 to 3 minutes. Rationale: Pressure helps stop
the bleeding and prevents hematoma formation.
Hold the clients arm above the body if any bleeding persists.
Rationale: Raising the limb decreases blood flow to the area.
3. Examine the catheter removed from the client.
Check the catheter to make sure it is intact. Rationale: If a
piece of tubing remains in the clients vein it could move
centrally (toward the heart or lungs) and cause serious
problems.
Report a broken catheter to the nurse in charge or primary
care provider immediately.
If a broken piece can be palpated, apply a tourniquet above
the insertion site. Rationale: Application of a tourniquet de-
creases the possibility of the piece moving until a primary
care provider is notified.
4. Cover the venipuncture site.
Apply the sterile dressing. Rationale: The dressing continues
the pressure and covers the open area in the skin, prevent-
ing infection.
Discard the IV solution properly, if infusions are being discon-
tinued, and discard the used supplies appropriately.
Record the amount of fluid infused on the intake and output
record and on the chart, according to agency practice. In-
clude the container number, type of solution used, time of
discontinuing the infusion, and the clients response.
EVALUATION
Appearance of the venipuncture site
The pulse
Respirations, skin color, edema, sputum, cough, and urine output
How the person feels physically and psychologically
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CHANGING AN INTRAVENOUS CATHETER TO AN INTERMITTENT INFUSION LOCK
PURPOSE
To permit IV administration of medications or fluids on an intermittent basis
ASSESSMENT
Patency of the IV catheter
Appearance of the site (evidence of inflammation or infiltration)
PLANNING
Review the primary care providers order.
A specific order may be written to convert an intravenous access
to a heparin or saline lock. The order also may be implied, for
example, IV fluids are to be discontinued but the client has or-
ders for an IV antibiotic every 6 hours or is receiving analgesics
intravenously.
Delegation
Due to the need for sterile technique and technical complexity,
this procedure is not delegated to UAP. UAP may care for clients
with such devices, and the nurse must ensure that the UAP
knows what complications or adverse signs should be reported
to the nurse.
Equipment
Intermittent infusion cap or device
Clean gloves
Sterile 2-in. 2-in. or 4-in. 4-in. gauze
Sterile saline for injection (without preservative) or heparin flush
solution (10 units/mL or 100 units/mL) in a prefilled syringe, a
3-mL syringe with a needleless infusion device
Isopropyl alcohol wipe
Tape
Clean emesis basin
IMPLEMENTATION
Preparation
the clients identity using agency protocol. Explain the proce-
dure to the client and the reason for leaving the IV catheter
in place. Changing an IV to a heparin or saline lock should
cause no discomfort other than that associated with remov-
ing tape from the IV tubing.
Performance
1. Prepare the equipment.
Perform hand hygiene.
Assess the IV site (if visible) and determine the patency of
the catheter (see Skill 52-2). If the catheter is not fully patent
or there is evidence of phlebitis or infiltration, discontinue
the catheter and establish a new IV site.
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Blood Transfusions
Intravenous fluids can be effective in restoring intravascular
(blood) volume; however, they do not affect the oxygen-
carrying capacity of the blood. When red and white blood
cells, platelets, or blood proteins are lost because of hemor-
rhage or disease, it may be necessary to replace these compo-
nents to restore the bloods ability to transport oxygen and
carbon dioxide, to clot, to fight infection, and to keep extra-
cellular fluid within the intravascular compartment. A blood
transfusion is the introduction of whole blood or blood com-
ponents into the venous circulation.
BLOOD GROUPS. Human blood is commonly classified into
four main groups (A, B, AB, and O). The surface of an indi-
viduals red blood cells contains a number of proteins known
as antigens that are unique for each person. Many blood anti-
gens have been identified, but the antigens A, B, and Rh are
the most important in determining blood group or type. Be-
cause antigens promote agglutination or clumping of blood
cells, they are also known as agglutinogens. The A antigen or
agglutinogen is present on the RBCs of people with blood
group A, the B antigen is present in people with blood group
B, and both Aand B antigens are found on the RBC surface in
people with group AB blood. Neither antigen is present in peo-
ple with group O blood.
Preformed antibodies to RBC antigens are present in the
plasma; these antibodies are often called agglutinins. People
with blood group Ahave B antibodies (agglutinins); Aantibod-
ies are present in people with blood group B; and people with
blood group O have antibodies to both A and B antigens. Peo-
ple with group AB blood do not have antibodies to either Aor B
antigens (Table 5211). When blood is transfused, the blood
CHANGING AN INTRAVENOUS CATHETER TO AN INTERMITTENT INFUSION LOCK continued
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Expose the IV catheter hub and loosen any tape that is hold-
ing the IV tubing in place or that will interfere with insertion
of the intermittent infusion plug into the catheter.
Clamp the IV tubing to stop the flow of IV fluid.
Open the gauze pad and place it under the IV catheter hub.
Open the alcohol wipe and intermittent infusion plug, leav-
ing the plug in its sterile package.
2. Remove the IV tubing and insert the intermittent infusion plug
into the IV catheter.
Put on gloves.
Stabilize the IV catheter with your nondominant hand and
use the little finger to place slight pressure on the vein above
the end of the catheter. Twist the IV tubing adapter to loosen
it from the IV catheter and remove it, placing the end of the
tubing in a clean emesis basin.
Pick up the intermittent infusion plug from its package and
remove the protective sleeve from the male adapter, main-
taining its sterility. Insert the plug into the IV catheter, twist-
ing it to seat it firmly or engage the Luer lock.
3. Instill saline or heparin solution per agency policy. Rationale:
Saline or heparin are used to maintain patency of the IV
catheter when fluids are not infusing through the catheter.
4. Tape the intermittent infusion plug in place using a chevron or
U method. Rationale: Tape provides added security to pre-
vent the infusion plug from coming out of the intravenous
catheter. It also promotes comfort, preventing the plug from
catching on clothing or bedding.
5. Teach the client how to maintain the lock.
Avoid manipulating the catheter or infusion plug and protect
it from catching on clothing or bedding. A gauze bandage
such as Kerlix or Kling may be wrapped over the plug when
it is not in use to protect it.
Cover the site with an occlusive dressing when showering;
avoid immersing the site.
Flush the catheter with saline or heparin solution as directed.
Notify the nurse or primary care provider if the plug or
catheter comes out; if the site becomes red, inflamed, or
painful; or if any drainage or bleeding occurs at the site.
EVALUATION
Patency of the catheter
Appearance of the site
Ease of flushing
CULTURALLY COMPETENT CARE
Blood and Blood Products
Jehovahs Witnesses do not receive blood or blood products.
Blood volume expanders are acceptable if they are not deriva-
tives of blood.
Christian Scientists do not ordinarily use blood or blood products.
Note: From Transcultural Concepts in Nursing Care (4th ed.) (pp. 470, 481), by
M. M. Andrews and J. S. Boyle, 2003, Philadelphia: Lippincott Williams & Wilkins.
Reprinted with permission.
TABLE 5211 The Blood Groups with Their
Constituent Agglutinogens and Agglutinins
BLOOD RBC ANTIGENS PLASMA ANTIBODIES
TYPES (AGGLUTINOGENS) (AGGLUTININS)
A A B
B B A
AB A and B
O A and B
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group of the donor and recipient must match to avoid an anti-
gen-antibody reaction and destruction (hemolysis) of RBCs.
RHESUS (RH) FACTOR. The Rh factor antigen is present on
the RBCs of approximately 85% of the people in the United
States. Blood that contains the Rh factor is known as Rh-
positive (Rh
); when it is not present the blood is said to be

Rh-negative (Rh
). In contrast to the ABO blood groups, Rh
blood does not naturally contain Rh antibodies. However, on

exposure to blood containing Rh factor (e.g., an Rh
mother
carrying a fetus with Rh
blood, or transfusion of Rh
blood
into a client who is Rh
), Rh antibodies develop. Subsequent

exposures to Rh
blood place the client at risk for an

antigenantibody reaction and hemolysis of RBCs.
BLOOD TYPING AND CROSSMATCHING. To avoid transfus-
ing incompatible red blood cells, both blood donor and recipi-
ent are typed and their blood crossmatched. Blood typing is
done to determine the ABO blood group and Rh factor status.
This test is also performed on pregnant women and neonates to
assess for possible intrauterine exposure of either to an incom-
patible blood type (particularly Rh factor incompatibilities).
Because blood typing only determines the presence of the
major ABO and Rh antigens, crossmatching also is necessary
prior to transfusion to identify possible interactions of minor
antigens with their corresponding antibodies. RBCs from the
donor blood are mixed with serum from the recipient; a reagent
(Coombs serum) is added, and the mixture is examined for vis-
ible agglutination. If no antibodies to the donated RBCs are
present in the recipients serum, agglutination does not occur
and the risk of transfusion reaction is small.
SELECTION OF BLOOD DONORS. Screening of blood donors
is rigorous. Criteria have been established to protect the donor
from possible ill effects of donation and to protect the recipi-
ent from exposure to diseases transmitted through the blood.
Blood donors are unpaid volunteers. Potential donors are
eliminated by a history of hepatitis, HIVinfection (or risk fac-
tors for HIV infection), heart disease, most cancers, severe
asthma, bleeding disorders, or convulsions. Donation may be
deferred for people with malaria or who have been exposed to
malaria or hepatitis or in situations of pregnancy, surgery, ane-
mia, high or low blood pressure, and certain drugs.
BLOOD AND BLOOD PRODUCTS FOR TRANSFUSION. Most
clients do not require transfusion of whole blood. It is more com-
mon for clients to receive a transfusion of a particular blood com-
ponent specific to their individual needs. Table 5212 lists some
of the common blood products that may be transfused.
TRANSFUSION REACTIONS. Transfusion of ABO- or Rh-
incompatible blood can result in a hemolytic transfusion reac-
tion with destruction of the transfused RBCs and subsequent
risk of kidney damage or failure. Other forms of transfusion
reaction also may occur, including febrile, allergic, circulatory
overload, and sepsis. Because the risk of an adverse reaction
is high when blood is transfused, clients must be frequently
and carefully assessed before and during transfusion. Many re-
actions become evident within 5 to 15 minutes of initiating the
transfusion but they can develop any time during a transfu-
sion; clients are closely monitored during the initial period of
the transfusion. Stop the transfusion immediately if signs of a
reaction develop. Possible transfusion reactions, their clinical
signs, and nursing implications are listed in Table 5213.
ADMINISTERING BLOOD. Special precautions are necessary
when administering blood.
When a transfusion is ordered, obtain the blood from the blood
bank just before starting the transfusion. Do not store the blood in
the refrigerator on the nursing unit; lack of temperature control
may damage the blood. Once blood or a blood product is removed
from the refrigerator, there is a limited amount of time to adminis-
ter it (e.g., packed RBCs should not hang for more than 4 hours af-
ter being removed from the refrigerator). Follow agency policies
TABLE 5212 Blood Products for Transfusion
PRODUCT USE
Whole blood
Packed red blood cells (PRBCs)
Autologous red blood cells
Platelets
Fresh frozen plasma
Albumin and plasma protein fraction
Clotting factors and cryoprecipitate
Not commonly used except for extreme cases of acute hemorrhage. Replaces blood volume and
all blood products: RBCs, plasma, plasma proteins, fresh platelets, and other clotting factors.
Used to increase the oxygen-carrying capacity of blood in anemias, surgery, and disorders with
slow bleeding. One unit of PRBCs has the same amount of oxygen-carrying RBCs as a unit of
whole blood (Rosenthal, 2004, p. 23). One unit raises hematocrit by approximately 2% to 3%.
Used for blood replacement following planned elective surgery. Client donates blood for
autologous transfusion 45 weeks prior to surgery.
Replaces platelets in clients with bleeding disorders or platelet deficiency. Fresh platelets most
effective. Each unit should increase the average adult clients platelet count by about 5,000
platelets/microliter (Rosenthal, 2004, p. 24).
Expands blood volume and provides clotting factors. Does not need to be typed and
crossmatched (contains no RBCs). Each unit will increase the level of any clotting factor by 2% to
3% in the average adult (Rosenthal, 2004, p. 26).
Blood volume expander; provides plasma proteins.
Used for clients with clotting factor deficiencies. Each provides different factors involved in the
clotting pathway; cryoprecipitate also contains fibrinogen.
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for verifying that the unit is correct for the client. The U.S. Food
and Drug Administration (FDA) requires blood products to have
bar codes to allow for scanning and machine-readable information
on blood and blood component container labels to help reduce
medication errors (FDA, 2004). Blood is usually administered
through a #18- to #20-gauge intravenous needle or catheter; using
a smaller needle may slow the infusion and damage blood cells (al-
though a smaller gauge needle may be necessary for small children
or clients with small, fragile veins). AY-type blood transfusion set
with an in-line or add-on filter is used when administering blood
(Figure 52-30 ). One arm of the administration set connects to the
blood; normal saline (0.9% NaCl) is attached to the other arm of
the Y-type set. Saline is used to prime the set and flush the needle
before administering blood. It also provides a means to keep the
vein open should a transfusion reaction occur. No other IV solu-
tions should be administered with blood; they may cause the blood
cells to clump or cause clotting. Atransfusion should be completed
within 4 hours of initiation. The risk of sepsis increases if blood
hangs for a longer period. Blood tubing is changed after every 4 to
6 units per agency policy; new intravenous tubing is used follow-
ing a transfusion.
CLINICAL ALERT
Normal saline should always be used when giving a blood transfusion.
If the client has an infusion of dextrose, stop that infusion and flush the
line with saline prior to initiating the transfusion. Solutions other than
saline can cause damage to the blood components.
To initiate, maintain, and terminate a blood transfusion, see
Skill 52-6.
TABLE 5213 Transfusion Reactions
REACTION: CAUSE CLINICAL SIGNS NURSING INTERVENTION
*
Hemolytic reaction:
incompatibility between
clients blood and donors
blood
Febrile reaction: sensitivity of
the clients blood to white
blood cells, platelets, or
plasma proteins
Allergic reaction (mild):
sensitivity to infused plasma
proteins
Allergic reaction (severe):
antibodyantigen reaction
Circulatory overload: blood
administered faster than the
circulation can accommodate
Sepsis: contaminated blood
administered
Chills, fever, headache,
backache, dyspnea, cyanosis,
chest pain, tachycardia,
hypotension
Fever; chills; warm, flushed
skin; headache; anxiety;
muscle pain
Flushing, itching, urticaria,
bronchial wheezing
Dyspnea, chest pain,
circulatory collapse, cardiac
arrest
Cough, dyspnea, crackles
(rales), distended neck veins,
tachycardia, hypertension
High fever, chills, vomiting,
diarrhea, hypotension
1. Discontinue the transfusion immediately.
NOTE: When the transfusion is discontinued, the blood tubing must be
removed as well. Use new tubing for the normal saline infusion.
2. Maintain vascular acess with normal saline, or according to agency
protocol.
3. Notify the primary care provider immediately.
4. Monitor vital signs.
5. Monitor fluid intake and output.
6. Send the remaining blood, bag, filter, tubing, a sample of the clients
blood, and a urine sample to the laboratory.
1. Discontinue the transfusion immediately.
2. Give antipyretics as ordered.
3. Notify the primary care provider.
4. Keep the vein open with a normal saline infusion.
1. Stop or slow the transfusion, depending on agency protocol.
3. Administer medication (antihistamines) as ordered.
1. Stop the transfusion.
2. Keep the vein open with normal saline.
3. Notify the primary care provider immediately.
4. Monitor vital signs. Administer cardiopulmonary resuscitation if needed.
5. Administer medications and/or oxygen as ordered.
1. Place the client upright, with feet dependent.
2. Stop or slow the transfusion.
4. Administer diuretics and oxygen as ordered.
1. Stop the transfusion.
2. Keep the vein open with a normal saline infusion.
4. Administer IV fluids, antibiotics.
5. Obtain a blood specimen from the client for culture.
6. Send the remaining blood and tubing to the laboratory.
*
Nurses should follow the agencys protocol regarding interventions. These may vary among agencies.
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Adapter
Y-Injection site
Slide clamp
Main flow rate
clamp
Blood filter
chamber
Drip chamber
Upper
clamps
Spikes
To saline
solution
To
blood
Figure 52-30 Schematic of a Y-set for blood administration.
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INITIATING, MAINTAINING, AND TERMINATING A BLOOD TRANSFUSION USING A Y-SET
PURPOSES
To restore blood volume after severe hemorrhage
To restore the oxygen-carrying capacity of the blood
To provide plasma factors, such as antihemophilic factor (AHF)
or factor VIII, or platelet concentrates, which prevent or treat
bleeding
ASSESSMENT
Clinical signs of reaction (e.g., sudden chills, fever, nausea, itch-
ing, rash, low back pain, dyspnea)
Manifestations of hypervolemia
Status of infusion site
Any unusual symptoms
PLANNING
Verify the primary care provider order for transfusion.
Verify client consent and obtain baseline data before the trans-
fusion.
Verify that a signed consent form was obtained.
Assess vital signs for baseline data, including blood pressure,
pulse, respiratory rate and depth, and temperature.
Determine any known allergies or previous adverse reactions to
blood.
Note specific signs related to the clients pathology and the rea-
son for the transfusion. For example, for an anemic client, note
the hemoglobin and hematocrit levels.
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Delegation
Due to the need for sterile technique and technical complexity,
blood transfusion is not delegated to UAP. The nurse must en-
sure that the UAP knows what complications or adverse signs
can occur and should be reported to the nurse.
Equipment
Blood product
Blood administration set
250 mL normal saline for infusion
IV pole
Venipuncture set containing a #18- to #20-gauge needle or
catheter (if one is not already in place) or, if blood is to be ad-
ministered quickly, a larger catheter
Chlorhexidine solution
Alcohol swabs
Tape
Clean gloves
IMPLEMENTATION
Preparation
the clients identity using agency protocol.
Explain the procedure and its purpose to the client. Instruct
the client to report promptly any sudden chills, nausea, itch-
ing, rash, dyspnea, back pain, or other unusual symptoms.
If the client has an intravenous solution infusing, check
whether the needle and solution are appropriate to admin-
ister blood. The preferred needle size is from #18 to #20
gauge, and the solution must be normal saline. Dextrose
(which causes lysis of RBCs), Ringers solution, medications
and other additives, and hyperalimentation solutions are in-
compatible. Refer to step 5 below if the infusing solution is
not compatible.
If the client does not have an IV solution infusing, check
agency policies. In some agencies an infusion must be run-
ning before the blood is obtained from the blood bank. In
this case, you will need to perform a venipuncture on a suit-
able vein (see Skill 52-1) and start an IV infusion of normal
saline.
Performance
1. Obtain the correct blood component for the client.
Check the primary care providers order with the requisition.
Check the requisition form and the blood bag label with a lab-
oratory technician or according to agency policy. Specifically,
check the clients name, identification number, blood type
(A, B, AB, or O) and Rh group, the blood donor number, and
the expiration date of the blood. Observe the blood for abnor-
mal color, RBC clumping, gas bubbles, and extraneous mate-
rial. Return outdated or abnormal blood to the blood bank.
With another nurse (most agencies require an RN), compare
the laboratory blood record with
a. The clients name and identification number.
b. The number on the blood bag label.
c. The ABO group and Rh type on the blood bag label.
If any of the information does not match exactly, notify the
charge nurse and the blood bank. Do not administer blood
until discrepancies are corrected or clarified.
Sign the appropriate form with the other nurse according to
agency policy.
Make sure that the blood is left at room temperature for
no more than 30 minutes before starting the transfusion.
Rationale: RBCs deteriorate and lose their effectiveness af-
ter 2 hours at room temperature. Lysis of RBCs releases
potassium into the bloodstream, causing hyperkalemia.
Agencies may designate different times at which the blood
must be returned to the blood bank if it has not been started.
Rationale: As blood components warm, the risk of bacterial
growth also increases. If the start of the transfusion is unex-
pectedly delayed, return the blood to the blood bank. Do not
store blood in the unit refrigerator. Rationale: The tempera-
ture of unit refrigerators is not precisely regulated and the
blood may be damaged.
2. Verify the clients identity according to agency protocol.
Check the clients arm band for name and ID number. Do
not administer blood to a client without an arm band.
3. Set up the infusion equipment.
Ensure that the blood filter inside the drip chamber is suit-
able for whole blood or the blood components to be trans-
fused. Attach the blood tubing to the blood filter, if necessary.
Rationale: Blood filters have a surface area large enough to
allow the blood components through easily but are de-
signed to trap clots.
Put on gloves.
Close all clamps on the Y-set: the main flow rate clamp and
both Y-line clamps.
Using a twisting motion, insert the piercing pin (spike) into a
container of 0.9% saline solution.
Hang the container on the IV pole about 1 m (36 in.) above
the venipuncture site.
4. Prime the tubing.
Open the upper clamp on the normal saline tubing and
squeeze the drip chamber until it covers the filter and one-
third of the drip chamber above the filter.
Tap the filter chamber to expel any residual air in the filter.
Remove the adapter cover at the tip of the blood adminis-
tration set.
Open the main flow rate clamp, and prime the tubing with
saline.
Close both clamps.
5. Start the saline solution.
If an IV solution incompatible with blood is infusing, stop the
infusion and discard the solution and tubing according to
agency policy.
Attach the blood tubing primed with normal saline to the in-
travenous catheter.
Open the saline and main flow rate clamps and adjust the
flow rate. Use only the main flow rate clamp to adjust the rate.
Allow a small amount of solution to infuse to make sure
there are no problems with the flow or with the venipunc-
ture site. Rationale: Infusing normal saline before initiating
the transfusion also clears the IV catheter of incompatible
solutions or medications.
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6. Prepare the blood bag.
Invert the blood bag gently several times to mix the cells with
the plasma. Rationale: Rough handling can damage the
cells.
Expose the port on the blood bag by pulling back the tabs.
Insert the remaining Y-set spike into the blood bag.
Suspend the blood bag.
Close the upper clamp below the IV saline solution on the
Y-set.
Open the clamp on the blood arm of the Y-set and prime the
tubing.
7. Establish the blood transfusion.
The blood will run into the saline-filled drip chamber. If nec-
essary, squeeze the drip chamber to reestablish the liquid
level with drip chamber one-third full. (Tap the filter to expel
any residual air within the filter.)
Readjust the flow rate with the main clamp.
8. Observe the client closely for the first 5 to 10 minutes.
Run the blood slowly for the first 15 minutes at 20 drops per
minute.
Note adverse reactions, such as chilling, nausea, vomiting,
skin rash, or tachycardia. Rationale: The earlier a transfusion
reaction occurs, the more severe it tends to be. Identifying
such reactions promptly helps to minimize the conse-
quences.
Remind the client to call a nurse immediately if any unusual
symptoms are felt during the transfusion.
If any of these reactions occur, report these to the nurse in
charge and take appropriate nursing action (see Table 5213).
9. Document relevant data.
Record starting the blood, including vital signs, type of blood,
blood unit number, sequence number (e.g., no. 1 of three
ordered units), site of the venipuncture, size of the needle,
and drip rate.
1/21/2008 1400 1 unit of PRBCs (#65234) hung to be in-
fused over 3 hours. IV site in (L) forearm with 19 G an-
giocath. VS taken (see transfusion record). Informed to
contact nurse if begins to experience any discomfort dur-
ing transfusion. Stated he would use the call light.
____________________________
C. Jones, RN.
10. Monitor the client.
Fifteen minutes after initiating the transfusion, check the vi-
tal signs of the client. If there are no signs of a reaction, es-
tablish the required flow rate. Most adults can tolerate
receiving one unit of blood in 1 1/2 to 2 hours. Do not trans-
fuse a unit of blood for longer than 4 hours.
Assess the client including vital signs every 30 minutes or
more often, depending on the health status, until 1 hour
post-transfusion. If the client has a reaction and the blood is
discontinued, send the blood bag and tubing to the labora-
tory for investigation of the blood.
11. Terminate the transfusion.
Put on clean gloves.
If no infusion is to follow, clamp the blood tubing and re-
move the needle. If another transfusion is to follow, clamp
the blood tubing and open the saline infusion arm. Blood ad-
ministration sets are changed within 24 hours or after 4 to 6
units of blood per agency protocol.
If the primary IV is to be continued, flush the maintenance
line with saline solution. Disconnect the blood tubing system
and reestablish the intravenous infusion using new tubing.
Adjust the drip to the desired rate. Often a normal saline or
other solution is kept running in case of delayed reaction to
the blood.
Discard the administration set according to agency practice.
Needles should be placed in a labeled, puncture-resistant
container designed for such disposal. Blood bags and ad-
ministration sets should be bagged and labeled before be-
ing sent for decontamination and processing. See agency
policy.
Remove gloves.
Again monitor vital signs.
12. Follow agency protocol for appropriate disposition of the blood
bag.
On the requisition attached to the blood unit, fill in the time
the transfusion was completed and the amount transfused.
Attach one copy of the requisition to the clients record and
another to the empty blood bag.
Return the blood bag and requisition to the blood bank.
13. Document relevant data.
Record completion of the transfusion, the amount of blood ab-
sorbed, the blood unit number, and the vital signs. If the pri-
mary intravenous infusion was continued, record connecting it.
Also record the transfusion on the IV flow sheet and I & O
record.
1/21/2008 1410 C/O feeling warm, headache and back-
ace. Skin flushed. Temp. 102.6, BP. 140/90, P. 112, R. 28.
Approximately 50100 cc infused. Infusion stopped.
Tubing changed and NS infusing at 15 cc/hr. Dr. Riley
notified.
______________________
C. Jones, RN
Exposing the port on the blood bag by pulling back the tabs.
S
K
I
L
L

5
2
-
6
koz74686_ch52.qxd 11/8/06 2:08 PM Page 1477
Evaluating
Using the overall goals identified in the planning stage of main-
taining or restoring fluid balance, maintaining or restoring pul-
monary ventilation and oxygenation, maintaining or restoring
normal balance of electrolytes, and preventing associated risks
of fluid, electrolyte, and acidbase imbalances, the nurse col-
lects data to evaluate the effectiveness of interventions. Exam-
ples of desired outcomes for the identified goals are found in
Identifying Nursing Diagnoses, Outcomes, and Interventions on
pages 1451 and 1452.
If desired outcomes are not achieved, the nurse, client, and
support person if appropriate need to explore the reasons before
modifying the care plan. For example, if the outcome Urine
output is greater than 1,300 mLper day and within 500 mLof in-
take is not achieved, questions to be considered might include
Have other outcome measures for the goal of achieving fluid
balance been met?
Does the client understand and comply with planned fluid intake?
Is all urinary output being measured?
Are unusual or excessive amounts of fluid being lost by an-
other route (e.g., gastric suction, excessive perspiration,
fever, rapid respiratory rate, wound drainage)?
Are prescribed medications being taken or administered as
ordered?
S
K
I
L
L

5
2
-
6
EVALUATION
Changes in vital signs or health status
Presence of chills, nausea, vomiting, or skin rash
NURSING CARE PLAN Deficient Fluid Volume
ASSESSMENT DATA NURSING DIAGNOSIS DESIRED OUTCOMES
*
Nursing Assessment
Merlyn Chapman, a 27-year-old sales clerk, reports weakness,
malaise, and flu-like symptoms for 34 days. Although thirsty, she
is unable to tolerate fluids because of nausea and vomiting, and
she has liquid stools 24 times per day.
Deficient Fluid Volume related
to nausea, vomiting, and diar-
rhea as evidenced by de-
creased urine output, increased
urine concentration, weakness,
fever, decreased skin/tongue
turgor, dry mucous mem-
branes, increased pulse rate,
and decreased blood pressure
Electrolyte & Acid/Base Bal-
ance [0600] as evidenced by
not compromised:
Serum electrolytes
Muscle strength
Fluid Balance [0601] as evi-
denced by not compromised:
24-hour intake and output
balance
Urine specific gravity
Blood pressure, pulse, and
body temperature
Skin turgor
Moist mucous membranes
Physical Examination
Height: 160 cm (53)
Weight: 66.2 kg (146 lb)
Mild fever: 38.6C (101.5F)
Pulse: 86 BPM
Respirations: 24/minute
Scant urine output
BP: 102/84 mm Hg
Dry oral mucosa, furrowed
tongue, cracked lips
Diagnostic Data
Urine specific gravity: 1.035
Serum sodium 155 mEq/L
Serum potassium 3.2 mEq/L
Chest x-ray negative
NURSING INTERVENTIONS
*
/SELECTED ACTIVITIES RATIONALE
Electrolyte Management: Hypokalemia [2007]
Obtain specimens for analysis of altered potassium levels (e.g.,
serum and urine potassium) as indicated.
Administer prescribed supplemental potassium (PO, NG, or IV)
per policy.
Monitor for neurologic and neuromuscular manifestations of hy-
pokalemia (e.g., muscle weakness, lethargy, altered level of con-
sciousness).
Urine and serum analysis provides information about extracellu-
lar levels of potassium. There is no practical way to measure in-
tracellular K
.
Low potassium levels are dangerous and Mrs. Chapman may
require supplements.
Potassium is a vital electrolyte for skeletal and smooth muscle
activity.
koz74686_ch52.qxd 11/21/06 1:08 PM Page 1478
NURSING CARE PLAN Deficient Fluid Volume continued
NURSING INTERVENTIONS*/SELECTED ACTIVITIES RATIONALE
Monitor for cardiac manifestations of hypokalemia (e.g., hypoten-
sion, tachycardia, weak pulse, rhythm irregularities).
Many cardiac rhythm disorders can result from hypokalemia. It is
critical to monitor cardiac function with hypokalemia.
Electrolyte Management: Hypernatremia [2004]
Obtain specimens for analysis of altered sodium levels (e.g.,
serum and urine sodium, urine osmolality, and urine specific grav-
ity) as indicated.
Provide frequent oral hygiene.
Monitor for neurologic and neuromuscular manifestations of hy-
pernatremia (e.g., lethargy, irritability, seizures, and hyperreflexia).
Monitor for cardiac manifestations of hypernatremia (e.g., tachy-
cardia, orthostatic hypotension).
Urine analysis provides information about retention or loss of
sodium and the ability of the kidneys to concentrate or dilute urine
in response to fluid changes.
Oral mucous membranes become dry and sticky due to loss of
fluid in the interstitial spaces.
Hypernatremia, as a result of low fluid volume, creates a hyper-
tonic vascular space, which causes water to move out of the cells,
including brain cells. This accounts for neurologic symptoms.
The heart responds to a loss of fluid by increasing the heart rate to
compensate with an increase in cardiac output. Low fluid volume
leads to a fall in blood pressure.
Fluid Management [4120]
Weigh daily and monitor trends.
Maintain accurate I & O record.
Monitor vital signs as appropriate.
Give fluids as appropriate.
Administer IV therapy as prescribed.
Weight helps to assess fluid balance.
Accurate records are critical in assessing the patients fluid balance.
Vital sign changes such as increased heart rate, decreased blood
pressure, and increased temperature indicate hypovolemia.
As her nausea decreases encourage her oral intake of fluids as tol-
erated, again to replace lost volume.
Mrs. Chapman has signs of severe fluid volume deficit. She will
probably require intravenous replacement of fluid. This is especially
true because her oral intake is limited because of nausea and
vomiting.
EVALUATION
Outcomes met. Mrs. Chapman remained hospitalized for 48 hours. She required fluid replacement of a total of 5 liters. Her blood pressure
increased to 122/74, pulse rate decreased to a resting level of 74, and respirations decreased to 12/minute. Her urine output increased as
the fluid was replaced and was adequate at > 0.5 mL/kg/hour by the time of discharge. The urine specific gravity was 1.015. Lab work on
the day of discharge was: K: 3.8 and Na: 140. She had elastic skin turgor and moist mucous membranes. She was taking oral fluids and
was able to discuss symptoms of deficient fluid volume that would necessitate her calling her health care provider.
*
The NOC # for desired outcomes and the NIC # for nursing interventions and seleted activities are listed in brackets following the appropriate out-
come or intervention. Outcomes, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further
individualized for each client.
APPLYING CRITICAL THINKING
1. What action would you take if Mrs. Chapmans heart became
irregular?
2. Mrs. Chapman is responding inappropriately to your questions;
she seems to be confused. What do you think is happening?
3. Offer suggestions for ways to help Mrs. Chapman increase her
oral intake.
4. Mrs. Chapman asks why you weigh her every morning. How do
you respond?
See Critical Thinking Possibilities in Appendix A.
koz74686_ch52.qxd 11/8/06 2:08 PM Page 1479
nursing intervention nursing intervention nursing intervention
Deficient Fluid Volume r/t nausea, vomiting, diarrhea aeb decreased urine output, increased urine
concentration, weakness, fever, decreased skin turgor, dry mucous membranes, increased pulse,
and decreased BP
MC
27 y.o. female
assess
generate nursing diagnosis
Sales clerk, Reports weakness,
malaise, and flu-like symptoms for 3-4
days. Although thirsty, is unable to
tolerate fluids because of nausea and
vomiting, and she has liquid stools 2-4
times per day.
Height: 160 cm (5' 3")
Weight: 66.2 kg (146 lbs)
T: 38.6C; P: 96 BPM;
R: 24; BP: 102/84
Dry mucous membranes
Decreased skin turgor
Urine specific gravity: 1.035
Serum sodium: 155 mEq/L
Serum potassium 3.2 mEq/L
Chest x-ray negative
Outcomes met:
Serum potassium:
3.8 mEq/L
Serum sodium:
140 mEq/L
outcome
outcome
evaluation
evaluation
Electrolyte and Acid/
Base Balance aeb
not compromised
Serum electrolytes
Muscle strength
Outcomes met:
BP: 122/74
P: 74
Urine output
increased
Specific gravity:
1.105
Moist mucous
membranes
Elastic skin turgor
Fluid balance aeb not
compromised
24 hour intake and output
Blood pressure, pulse,
and temperature
Skin turgor
Urine specific gravity
Mucous membranes
Obtain specimens
for analysis of
altered potassium
levels as indicated
Administer prescribed
supplemental
potassium (PO, NG, or
IV) per policy
Monitor for
neurologic and
neuromuscular
manifestations of
hypernatremia
(e.g., lethargy,
irritability,
seizures,
and
hyperreflexia)
Provide
frequent
oral
hygiene
Weigh
daily and
monitor
trends
Give
fluids as
appropriate
Monitor
vitals signs
as appropriate
Maintain
accurate
intake and
output
record
Administer IV
therapy as
prescribed
Obtain specimens for analysis of altered
sodium levels (e.g., serum and urine
sodium, urine osmolality, and urine specific
gravity) as indicated
Monitor for
cardiac
manifestations of
hpyernatremia
(e.g., tachycardia,
orthostatic
hypotension)
Monitor for
neurologic and
neuromuscular
manifestations
of hypokalemia
(e.g., hypotension,
tachycardia,
weak pulse, rhythm
irregularities)
activity
activity
activity
activity
activity
activity
activity
activity
activity
activity
activity
activity
Fluid Management Behavior Modification Electrolyte Management: Hypernatremia
CONCEPT MAP Deficient Fluid Volume
koz74686_ch52.qxd 11/8/06 2:08 PM Page 1480
CHAPTER 52 REVIEW
CHAPTER HIGHLIGHTS
A balance of fluids, electrolytes, acids, and bases in the body is
necessary for health and life.
The body fluid is divided into two major compartments: the
intracellular fluid (ICF) inside the cells and extracellular fluid (ECF)
outside the cells.
Extracellular fluid is subdivided into two compartments:
intravascular (plasma) and interstitial. It constitutes about one-
fourth to one-third of total body fluid.
ECF is in constant motion throughout the body. It is the transport
system that carries nutrients to and waste products from the cells.
The percentage of total body fluids varies according to the
individuals age, body fat, and sex. The younger the person, the
higher the proportion of water in the body. The less body fat
present, the greater the proportion of body fluid. Postadolescent
females have a smaller percentage of fluid in relation to total body
weight than do men.
There are two types of body electrolytes (ions): positively charged
ions (cations) and negatively charged ions (anions).
The principal ions of ECF are sodium and chloride; the principal
ions of ICF are potassium and phosphate.
Fluids and electrolytes move among the body compartments by
osmosis, diffusion, filtration, and active transport.
The major fluid pressures exerted as part of the movement of fluid
and electrolytes from one compartment to another are osmotic
pressure and hydrostatic pressure.
The three sources of body fluid are fluids taken orally, food
ingested, and the oxidation of food. Fluid intake is regulated by the
thirst mechanism.
Fluid output occurs chiefly through excretion of urine, although body
fluid is also lost through sweat, feces, and insensible vapor loss.
In healthy adults, measurable fluid intake and output should
balance (about 1,500 mL per day). The output of urine normally
approximates the oral intake of fluids. Water from food and
oxidation is balanced by fluid loss through the skin, respiratory
process, and feces.
A number of body systems and organs are involved in regulating
the volume and composition of body fluids: the kidneys, the
endocrine system, the cardiovascular system, the lungs, and the
gastrointestinal system. The kidneys are the primary regulator of
fluid and electrolyte balance.
Substances such as the antidiuretic hormone, the renin-
angiotensin-aldosterone system, and the atrial natriuretic factor are
also involved in maintaining fluid balance.
Fluid imbalances include
a. Fluid volume deficit (FVD), also referred to as hypovolemia.
b. Fluid volume excess (FVE), also referred to as hypervolemia.
c. Dehydration, a deficit in water and increase in serum
sodium level.
d. Overhydration, an excess of water and decrease in serum
sodium level.
The most common electrolyte imbalances are deficits or excesses
in sodium, potassium, and calcium.
The acidbase balance (pH range) of body fluids is maintained
within a precise range of 7.35 to 7.45.
Acidbase balance
is regulated by
buffers that neutralize
excess acids or bases; the
lungs, which eliminate or retain carbon dioxide, a potential acid;
and the kidneys, which excrete or conserve bicarbonate and
hydrogen ions.
Acidbase imbalance occurs when the normal 20-to-1 ratio of
bicarbonate to carbonic acid is upset. Imbalances may be either
respiratory or metabolic in origin; either can result in acidosis or
alkalosis.
Factors that influence an individuals fluid, electrolyte, and
acidbase balance include age, gender and body size,
environmental temperature, and lifestyle. Illness, trauma, surgery,
and certain medications can place individuals at risk for fluid,
electrolyte, and acidbase imbalances.
Fluid, electrolyte, and acidbase imbalance is most accurately
determined through laboratory examination of blood plasma.
Assessment relative to fluid, electrolyte, and acidbase balances
includes (a) a nursing history; (b) physical examination of the
skin, oral cavity, eyes, jugular vein, veins of the hand, and the
neurologic system; (c) measurement of body weight, vital signs,
and fluid intake and output; and (d) various diagnostic studies of
blood and urine.
A nursing history includes data about the clients fluid and food
intake; fluid output; signs of fluid, electrolyte, and acidbase
imbalances; and medications, therapies, or disease processes that
may disrupt these balances.
NANDA-approved nursing diagnoses that relate specifically to fluid,
electrolyte, and acidbase imbalances include Deficient Fluid
Volume, Excess Fluid Volume, Risk for Imbalanced Fluid Volume,
Risk for Deficient Fluid Volume, and Impaired Gas Exchange. Other
diagnoses that may be relevant are Impaired Oral Mucous
Membrane, Impaired Skin Integrity, Decreased Cardiac Output,
Impaired Tissue Perfusion, Activity Intolerance, Risk for Injury, and
Acute Confusion.
In many instances, fluids and electrolytes can be provided orally to
clients who are experiencing or at risk of developing fluid deficits.
The nurse needs to establish with the client a 24-hour plan for
ingesting the necessary fluids and to respect the clients fluid
preferences.
For clients with fluid retention, fluids may need to be restricted; a
schedule and short-term goals that make the fluid restriction more
tolerable need to be developed.
For clients experiencing excessive fluid losses, the administration of
fluids and electrolytes intravenously is necessary. Meticulous
aseptic technique is required when caring for clients with
intravenous infusions.
Preventing complications such as infiltration, phlebitis,
hypervolemia (circulatory overload), and infection is an important
aspect of intravenous therapy.
The administration of blood transfusions involves accurately
matching and identifying the blood for the individual, correctly
identifying the recipient, and monitoring the client throughout the
procedure for transfusion reactions.
koz74686_ch52.qxd 11/8/06 2:08 PM Page 1481
TEST YOUR KNOWLEDGE
1. An elderly nursing home resident has refused to eat or drink for
several days and is admitted to the hospital. The nurse should
assess for which of the following?
1. Increased blood pressure
2. Weak, rapid pulse
3. Moist mucous membranes
4. Jugular vein distention
2. A man brings his elderly wife to the emergency department. He
states that she has been vomiting and has had diarrhea for the
past 2 days. She appears lethargic and is complaining of leg
cramps. What should the nurse do first?
1. Start an IV.
2. Review the results of serum electrolytes.
3. Offer the woman foods that are high in sodium and
potassium content.
4. Administer an antiemetic.
3. The nurse administers an IV solution of D5
1
2 NS to a
postoperative client. This is classified as what type of
intravenous solution? ___________
4. An older client comes to the emergency department
experiencing chest pain and shortness of breath. An arterial
blood gas is ordered. Which of the following ABG results
indicates respiratory acidosis?
1. pH 7.54; PaCO
2
28 mm Hg; HCO
3
22 mEq/L
2. pH 7.32; PaCO
2
46 mm Hg; HCO
3
24 mEq/L
3. pH 7.31; PaCO
2
35 mm Hg; HCO
3
20 mEq/L
4. pH 7.50; PaCO
2
37 mm Hg; HCO
3
28 mEq/L
5. The intake and output (I & O) record of a client with a
nasogastric tube that has been attached to suction for two (2)
days shows greater output than input. Which nursing diagnoses
are most applicable? Select all that apply.
1. Deficient Fluid Volume
2. Risk for Deficient Fluid Volume
3. Impaired Oral Mucous Membranes
4. Impaired Gas Exchange
5. Decreased Cardiac Output
6. Which of the following client statements indicates a need for
further teaching regarding treatment for hypokalemia?
1. I will use avocado in my salads.
2. I will be sure to check my heart rate before I take my
digoxin.
3. I will take my potassium in the morning after eating
breakfast.
4. I will stop using my salt substitute.
7. An elderly man is admitted to the medical unit with a diagnosis
of dehydration. Which of the following signs or symptoms are
most representative of a sodium imbalance?
1. Hyperreflexia
2. Mental confusion
3. Irregular pulse
4. Muscle weakness
8. The clients arterial blood gas results are: pH 7.32; PaCO
2
58;
HCO
3
32. The nurse knows that the client is experiencing which
acidbase imbalance?
1. Metabolic acidosis
2. Respiratory acidosis
3. Metabolic alkalosis
4. Respiratory alkalosis
9. A client is admitted to the hospital for hypocalcemia. Nursing
interventions relating to which system would have the highest
priority?
1. Renal
2. Cardiac
3. Gastrointestinal
4. Neuromuscular
10. The nurse would assess for signs of hypomagnesemia in which
of the following clients? Select all that apply.
1. A client with renal failure
2. A client with pancreatitis
3. A client taking magnesium-containing antacids
4. A client with excessive nasogastric drainage
5. A client with chronic alcoholism
See Answers to Test Your Knowledge in Appendix A.
EXPLORE MEDIALINK www.prenhall.com/berman
DVD-ROM
Audio Glossary
NCLEX Review
Skills Checklists
Animations:
Membrane Transport
Filtration Pressure
Fluid Balance
AcidBase Balance
Furosemide Drug
Applying a Central Venous Line
COMPANION WEBSITE
Additional NCLEX Review
Case Study: Client with Suspected Electrolyte Imbalance
Care Plan Activity: Client with Heart Failure
Application Activities:
Determining Body Fluid Problems
Arterial Blood Gases and AcidBase Balance
Links to Resources
koz74686_ch52.qxd 11/8/06 2:08 PM Page 1482
CHAPTER 52 / Fluid, Electrolyte, and Acid-Base Balance 1483
READINGS AND REFERENCES
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important safety checks of IV medication
administration. Having this mnemonic written
on the nurses clipboard will help the nurse to
stay focused on the task in a hectic and
stressful working environment. The article
explains how each letter pertains to important
safety checks when administering IV
medications.
Davidhizar, R., Dunn, C. L., & Hart, A. N. (2004). A
review of the literature on how important
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Mentes, J. (2006). Oral hydration in older adults.
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This author provides information on an array
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Fluids and Electrolytes

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Fluid,

) and one ion of chloride (Cl

). Thus, 1 mEq of any anion equals 1 mEq of any

. However, these cations and anions are not equal in

does not equal 1 mg of Cl

) and retaining bicarbonate.

into cells; tissue damage and

out of cells into ECF

Phosphate is the major anion of intracellular fluids. It also is

Bicarbonate is present in both intracellular and extracellular flu-

) and carbonic acid (H

), the most abundant cation in the extracellular

levels carefully; a rapid drop

), imbalances of chloride commonly occur in conjunc-

is found in both intracellular and ex-

) in the body exists

. Phosphate is critical for cellular metabolism because it

normal or slightly elevated in acute;

: a measure of the metabolic component

is less than 22 mEq/L, bicarbonate levels are

is greater than 26 mEq/L, bicarbonate levels are

which one MATCHES the same

is greater than 26 mEq/L, the kidneys are retain-

is less than 22 mEq/L, the kidneys are ex-

Assess location and extent of edema

Monitor for indications of fluid over-

Maintain accurate intake and output

Weigh daily and monitor trends

Consult primary care provider if signs

Monitor respiratory pattern

Monitor ABG levels for decreasing pH

Monitor neurological status (e.g., level

Monitor determinants of tissue oxy-

Provide mechanical ventilatory sup-

. Saline and balanced electrolyte solutions

15. Ensure appropriate infusion flow.

This labeling may also be done when the in-

Place a small gauze square under the

); when it is not present the blood is said to be

). In contrast to the ABO blood groups, Rh

blood does not naturally contain Rh antibodies. However, on

), Rh antibodies develop. Subsequent

blood place the client at risk for an

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