1. Chapter 16 Fluid and Chemical Balance

2. OBJECTIVES Name four components of body fluid.
List five physiologic transport mechanisms for distributing fluid and its constituents.
Name 10 assessments that provide data about a client’s fluid status.
Describe three methods for maintaining or restoring fluid volume.
Describe four methods for reducing fluid volume.
List six reasons for administering intravenous (IV) fluids.
Differentiate between crystalloid and colloid solutions, and give examples of each.
Explain the terms isotonic, hypotonic, and hypertonic when used in reference to IV solutions.
List four factors that affect the choice of tubing used to administer IV solutions.
Name three techniques for infusing IV solutions.
Discuss at least five criteria for selecting a vein when administering IV fluid.
List seven complications associated with IV fluid administration.
Discuss two purposes for inserting an intermittent venous access device.
Identify three differences between administering blood and crystalloid solutions.
Name at least five types of transfusion reactions.
Explain the concept of parenteral nutrition.

3. Chapter 16: Fluid and Chemical Balance
Body fluid is a mixture of water, chemicals (called electrolytes and nonelectrolytes), and blood cells.
Water, the vehicle for transporting the chemicals, is the very essence of life.
Water is not stored in any great reserve, daily replacement is the key to maintaining survival.

4. Body Fluid Body fluid is a mixture of:
Water: human body has 45% to 75%
Electrolytes: have electrical charge
Nonelectrolytes: do not have electrical charge
Blood cells: RBCs, Leukocytes, WBCs, Platelets

5. Electrolytes
Possess an electrical charge when dissolved, absorbed, & distributed (sodium & chloride)
Obtained from dietary sources
Essential for maintaining cellular, tissue, & organ functions (muscle contractions)
Ions (+ or -), cations (+), anions (-); distributions vary per fluid compartment
Loss may occur through altered state of health, or inability to eat

6. Nonelectrolytes Remain bound together when dissolved
Do not possess an electrical charge
Chemical end products of carbohydrates, fats, & proteins (glucose, fatty acids, amino acids)
Provide a continuous supply of non- electrolytes
Stable amounts circulate in body fluid as long as a person consumes adequate nutrients

7. Body Fluid Distribution

8. Intracellular / Extracellular Fluid
Intracellular fluid: Fluid inside cells (greatest portion of water in the body)
Extracellular fluid: Fluid outside cells
** Extracellular fluid is one of the following:
Interstitial fluid (fluid in tissues)
Intravascular fluid (the watery plasma, or serum, portion of blood)

9. Fluid Transport Mechanisms
Osmosis: regulate the distribution of water by controlling the movement of fluid from one location to another
H2O moves through a semipermeable membrane like those surrounding body cells, capillary walls, body organs and cavities.
From areas where the fluid is more dilute to another area where the fluid is more concentrated.
Produces colloidal osmotic pressure

10. Fluid Transport Mechanisms
Filtration: regulates the movement of water and substances from a compartment with high pressure to one with lower pressure
Governs how the kidneys excretes fluid & wastes & then selectively reabsorbs H2O & substances that need to be conserved
AKA: hydrostatic pressure

11. Fluid Transport Mechanisms
Passive diffusion: High concentration to lower concentration through semipermeable membrane
Occurs without expenditure of energy.. An absorption process that occurs in the body when carbohydrates are more highly concentrated in the intestine than in the blood. Very much like osmosis.
Ex: O2 enters all cells passively, CO2 leaves all cells passively.
Electrochemical neutrality (identical balance of cations with anions)

12. Fluid Transport Mechanisms
Facilitated diffusion: process where substances require the assistance of a carrier molecule to pass from one side of a semipermeable membrane to the other.
Ex: Glucose requires Insulin as the carrier substance because it binds to receptor proteins which then transport it into cells.

13. Fluid Transport Mechanisms
Active transport: process of chemical distribution that requires energy source, adenosine triphosphate (ATP).
Allows chemical distribution from low concentration to one that is higher (opposite of passive diffusion).
Ex: sodium-potassium pump on cellular membranes => K+ into cells and Na+ out of cells

14. Osmosis
left: The concentration of sugar molecules is greater on the right side of the membrane than on the left. The water molecules are small enough to move across the membrane, but the larger sugar molecules cannot pass through.
right: The water molecules move across the membrane until the water and sugar molecules are of equal concentration on both sides. This lowers the water level on the left side and raises it on the right side.

15. Passive Diffusion Before diffusion
Left beaker: has less red molecules than the beaker on the on right side of the membrane.
After diffusion
Right beaker: has equal amounts of red and black molecules, but the fluid level has not changed.

16. Fluid Transport Mechanisms

17. Assessing a Client’s Fluid Status
Intake and output (I&O) measurement: one tool to assess fluid status by keeping record over a 24hr period.
Intake: Sum of all fluid consumed/instilled
Output: Sum of liquid eliminated from the body

18. Assessing a Client’s Fluid Status: Intake
All liquids client drinks
IV solutions given
Liquid equivalent of melted ice chips, which is half of the frozen volume
Foods that liquidize when swallowed: gelatin, ice cream, thin cooked cereal
Fluid instillations: tube feeds or tube irrigations

19. Assessing a Client’s Fluid Status: Output
Urine Emesis (vomitus) Blood loss Diarrhea Wound or tube drainage Aspirated irrigations

20. Assessing Fluid Status
Fluid volumes are recorded in milliliters (mL). 1 oz = 30 mL 1 cup = 8 oz = 240 mL 1 tsp = 5 mL 1 tbsp = 15 mL Nursing homes & hospitals usually provide equivalency charts from dietary department. If one is not available the nurse uses a calibrated container to measure specific amounts; estimated volumes are considered inaccurate (see Box 16-2 p.309)

21. Assessing Fluid Status
Calibrated containers used to measure liquid volumes.

22. Intake and output record

23. Assessing a Client’s Fluid Status
Clients Commonly Place on I&Os Automatically
Post surgery: until eating, drinking and voiding in sufficient qualities
Clients receiving IV fluids
Clients receiving tube feedings
Clients with wound drainage or suction equipment

24. Assessing a Client’s Fluid Status
Clients with urinary catheters until it can be determined the output is adequate or they are voiding well after removal of the catheter
Clients undergoing diuretic drug therapy

25. Common Fluid Imbalances
Hypovolemia: low volume in extracellular fluid compartments
Dehydration: fluid deficit in both extracellular & intracellular compartments. In addition to weight loss, it is evidenced by decreased skin turgor (usually checked over the sternum)

26. Common Fluid Imbalances
Dehydration: (p. 311)
Mild: 3%-5% loss of body weight
Moderate: 6%-10% loss of body weight
Severe: more than 9%-15% of body weight

27. Common Fluid Imbalance
Dehydration: Table 16-4, page 315
Physical S&S: Acute wt loss, Oliguria, concentrated urine, sunken eyes, poor skin turgor, low BP, weak rapid pulse, sleepy.
Lab values when suspecting dehydration:
High Na+, Low K+ =>muscle cramps, High BUN & CR, thirst & confusion.

28. Common Fluid Imbalances
Hypervolemia: excess water in intravascular fluid compartment
Edema: excess fluid distributed to the interstitial space
Dependent edema: fluid accumulates in dependent areas of the body (influenced by gravity)
Box 13-2 Criteria Estimating Pitting Edema (Ch. 13, p. 249)

29. Figure 16-6 Foot care is very important for the client with edema
Figure 16-6 Foot care is very important for the client with edema. The edema and reddened areas can easily break down.

30. Common Fluid Imbalances
Third-spacing: movement of intravascular fluid to nonvascular fluid compartment s, where it becomes trapped and useless
Peritoneum common place for fluid build-up
Hypoalbuminemia (deficit of albumin in the blood). Ex: liver disease, chronic kidney disease, burns and severe allergic reactions

31. Figure 16-6 Fluid accumulation within the peritoneal cavity
Figure Fluid accumulation within the peritoneal cavity. Dullness on percussion indicates fluid, whereas tympany indicates air. (p. 319)

32. Third Spacing Treatment:
Depletion of fluid in the intravascular space may lead to hypotension and shock => fluid therapy becomes critical.
Done through IV fluids, sometimes in large rapid amounts. Blood transfusions/Albumin by IV are also used to restore colloidal osmotic pressure and to pull the trapped fluid back into the intravascular space.
When this is done, clients who were previously hypovolemic can suddenly become hypervolemic. Requires close monitoring for circulatory overload (acute respiratory distress and CHF).

33. Conditions Predisposing to Fluid Imbalance Box 16-1, page 315
Fluid Deficit:
Starvation Potent diuretics
Impaired swallowing Hemorrhage
Vomiting/Diarrhea Major burns
Gastric suction Draining wounds
Fever & sweating Exercise & sweating
Laxative abuse Heat & humidity

34. Conditions Predisposing to Fluid Imbalance Box 16-1, page 315
Fluid Excess: Kidney Failure Heart Failure (CHF) Rapid admin of IV fluid Admin of albumin or blood Pregnancy Excessive Na+ intake Corticosteroid drug PMS therapy (premenstrual fluid retention)

35. Restoring Fluid Volume
Treating the cause of hypovolemia
Increasing oral intake
Administering IV fluid replacements
Controlling fluid losses
Using a combination of these measures

36. Restoring Fluid Volume
IV Fluids:
Maintain/restore fluid balance when oral replacement is inadequate/impossible
Maintain/replace electrolytes
Administer water-soluble vitamins
Provide a source of calories
Administer drugs
Replace blood and blood products

37. Reducing Fluid Volume
Treating the disorder contributing to the increased fluid volume
Restricting or limiting oral fluids
Reducing salt consumption
Discontinuing IV fluid infusions or reducing the infusing volume
Administering drugs that promote urine elimination
Using a combination of the above interventions

38. Question Is the following statement true or false?
Reducing salt consumption helps restore fluid volume.

39. Answer
False. Reducing salt consumption helps reduce fluid volume.

40. Administering Intravenous Fluids
Maintain or restore fluid balance when oral replacement is inadequate or impossible
Maintain or replace electrolytes
Administer water-soluble vitamins
Provide a source of calories
Administer drugs
Replace blood and blood products

41. Crystalloid Solutions
Crystalloid solutions are classified as isotonic, hypotonic and hypertonic, depending on the concentration of dissolved substances in relation to plasma.
Crystalloid solutions: made of water and other uniformly dissolved crystals such as salt and sugar

42. Types of Intravenous Solutions table 16-5, page 321
Isotonic: contains the same concentration of dissolved substances as normally found in plasma (yellowish liquid component of blood that normally holds the blood cells in whole blood in suspension).
Generally administered to maintain fluid balance in clients who may not be able to eat/drink for a short period
Does not cause any appreciable redistribution of body fluid
Ex: 0.9% saline (NS), D5W, LR

43. Types of Intravenous Solutions
Hypotonic: contains fewer dissolved substances than normally found in plasma. Temporarily increases blood pressure as it expands the circulating volume.
Given to clients with fluid losses greater than fluid intake, diarrhea/vomiting. Effective way to rehydrate clients who have fluid deficits.
The water in the solution passes through the semipermeable membrane of blood, causes them to swell
Ex: 0.45% sodium chloride, D5.45 NS

44. Types of Intravenous Solutions
Hypertonic: more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment
Causes cells and tissues to shrink
Used in extreme cases when it is necessary to reduce cerebral edema or expand circulatory volume rapidly.
Ex: D10W, 3% saline, D20

45. IV Solutions
A. Isotonic solutions B. Hypotonic solutions (cell swelling) C. Hypertonic solutions (cell shrinkage)

47. Colloid Solutions
Colloid solutions: made of water and molecules of suspended substances such as blood cells and blood products (such as albumin).
Used to replace circulating blood volume, will pull fluid from other compartments
Ex: blood, blood products, solutions known as plasma expanders, blood substitutes

48. Plasma Expanders
Various non-blood solutions used to pull fluid into the vascular space
Used to increase blood volume and raise blood pressure
Colloidal solutions (formed when mixed with water)
Hespan
Dextran 40

49. Question Is the following statement true or false?
Blood is an example of crystalloid solution.

50. Answer
False. Blood is an example of colloid solution.

51. Blood Substitutes
Blood substitutes: Fluids that when carry and distribute O2 to cells, tissues and organs.
Many feel they should be called O2 therapeutics because they do not replace all the functions of human blood.

52. Blood Substitutes Advantages:
Would be an acceptable alternative for Jehovah’s Witnesses
Would be beneficial to tose tha require long- term blood transfusions
Risks of blood-born diseases, such as Hepatitis and AIDS, and transfusion reactions could be eliminated
Greater potential for saving the lives of military casualties in primitive locations

53. Blood Substitutes
Can be kept at room temperature and most carrier in trials today carry a shelf life of between 1-3 years.
Donated blood needs to be refrigerated and has a shelf life of days.
Rapid treatment of clients in trauma/disaster situations while awaiting blood. They don’t contain any of the antigens that determine blood type, can be used across all types without immunology reactions.

54. Solution Selection
IV solutions usually come in plastic bags: 1000 ml 500 ml 250 ml 100 ml 50 ml

55. IV Solutions
MD specifies type and additives, the volume (in mL) and duration of infusion.
Nurse replaces IV bags every 24hrs to prevent infection even if the total volume has not been completely instilled.

56. IV Solutions
Before preparing the solution, the nurse inspects the container and determines that:
Solution is the one prescribed
Solution is clear and transparent
Expiration date has not elapsed
No leaks are present
A separate label is attached identifying the type & amount of other drugs added and is the one the MD ordered.

57. Types of Tubing
Primary (long) tubing: used when tubing must span the distance from a solution hanging several feet above the infusion site
Secondary (short) tubing: used to administer smaller amounts of solution into a port within the primary tubing

58. Types of Tubing Vented or unvented tubing
Vented: used for bottled solutions. If unvented tubing is inserted into a glass bottle, solution will not leave the bottle
Unvented: used for plastic bags because the bag collapses as the fluid infuses

59. Unvented and Vented Tubing

60. Types of Tubing
Microdrip (small drops) chamber: standard volume of 60 drops/mL
Macrodrip (large drops) chamber: usually 10, 15, and 20 drops/mL.
Drop factor (number of drops/mL) is important in calculating infusion rate when infusion is done by gravity

61. Types of Tubing Unfiltered or filtered tubing
Filtered: removes air bubbles, undissolved drugs, bacteria, large substances
Ex: PRBCs, parental nutrition, pediatric clients

62. Types of Tubing Needleless access ports:
To reduce the incidence of work-related injuries and potential for infection with blood-borne pathogens, needleless systems are preferred. Uses blunt cannulas. IV tubing that eliminates the need for access needles.
Needle access ports:
Port that requires a needle for access cannot be punctured with a blunt cannula

63. Needleless Systems

64. Techniques for Infusing Intravenous Solutions
Gravity infusion-height of the IV solution is the most important factor affecting gravity infusions
Electronic infusion devices
Infusion pumps
Volumetric controllers

66. Vein Selection Potential venipuncture device insertion locations:
Hand or forearm in adults
Scalp in child

67. Complications With IV Administration
Circulatory overload
Infiltration; Phlebitis
Thrombus formation
Pulmonary embolus
Infection; Air embolism

68. Inserting an Intermittent Venous Access Device
When client no longer needs continuous infusions of fluid
When client needs intermittent IV medication
When client needs emergency IV fluid or medications

69. Intermittent Venous Access Device

70. Blood Administration Blood collection and storage Blood safety
Blood compatibility
Blood transfusion
Blood transfusion equipment
Catheter or needle gauge
Blood transfusion tubing

71. Blood Administration
Blood donors screened to ensure health enough to donate.
Donated blood is tested for Syphilis, Hepatitis, HIV antibodies
Disease-carrying viruses may be there if antibodies have not reached measurable levels
Notification to blood recipients before if donor tests Hep C+ since 1990

72. Blood Compatibility
Danger of transfusion reaction from antigen, or protein structures, on membranes of RBCs
Antigens determine blood grouping: A, B, AB, and O ---- and Rh factor
Rh+ means the protein is present
Rh- means the protein is absent

73. Blood Compatibility
Before blood administration, blood of recipient is typed and mixed, or cross- matched (T&C) with a sample of the stored blood to determine whether the two are compatible.
It is best to administer the same blood group and Rh factor.
Exceptions to this rule are on p. 329
Table 16-8

74. Blood Compatibility
Type O blood is considered universal because it lacks both A&B blood group markers on its cell membranes.
People with type AB blood are universal blood recipients because their RBCs have proteins compatible with types A, B and O.
An Rh- person should never receive Rh+ blood
Rh+ can receive Rh+ or Rh- blood because the latter does not contain the sensitizing protein.

75. Blood Administration
Infused through 16-gauge to 20-gauge preferably 18-gauge catheter
4 hours is the maximum time for administering 1 unit of blood.

77. Blood Transfusion
Before administering blood: VS obtained & documented – baseline Color-coded bracelet check number check, have to correspond with unit of blood IV meds are never infused through tubing being used to administer blood

78. Transfusion Reactions
Incompatibility
Febrile
Septic
Allergic
Moderate chilling
Overload
Hypocalcemia

79. Transfusion Reactions
Usually occur within first 5-15 minutes of the transfusion
Staff remains with client for the 1st 15 minutes
See Table 16-9 Transfusion Reactions p.331

80. Parenteral Nutrition
Intravenous administration of nutrients such as protein, carbohydrate, fat, vitamins, minerals, and trace elements
Peripheral parenteral nutrition
Total parenteral nutrition
Lipid emulsions

81. Parenteral Nutrition
PPN (temporary nutrition): isotonic or hypotonic IV nutrient solution instilled in a vein distant from the heart. Not extremely concentrated, can be infused through peripheral veins. Can be used for people who are not eating for 7-10 days.
TPN: hypertonic solution of nutrients to meet almost all caloric and nutritional needs. Preferred for clients severely malnourished or may not be able to consume food or liquids for a long period.

82. Parenteral Nutrition
TPN is extremely concentrated. Must be delivered to an area where it can be diluted with large volume of blood, this excludes peripheral veins. TPN is transfused through a catheter inserted into the subclavian or jugular vein; tip ends in the superior vena cava

83. Central venous cath inserted into subclavian vein and threaded into superior vena cava.
Peripherally inserted cath (PICC) with the distal tip in the superior vena cava.

84. Question Is the following statement true or false?
The venipuncture device is inserted in hand veins in infants or small children.

85. Answer
False. The venipuncture device is inserted in scalp veins in infants or small children.

86. General Gerontologic Considerations
Older adults at risk for fluid and electrolyte imbalances due to cardiac meds and chronic conditions
Encourage fluid intake to keep oral mucosa moist and provides hydration
Offer noncaffeinated beverages; offer fluids at non-meal times
When fasting before procedures, ensure prior increased oral fluid intake

87. General Gerontologic Considerations (cont’d)
Indicators of dehydration
Test skin turgor over sternum
Mental status changes
Increased pulse and respiration rates
Decreased blood pressure
Dark, concentrated urine with high specific gravity

88. General Gerontologic Considerations (cont’d)
Indicators of dehydration (cont’d)
Dry mucous membranes
Warm skin, furrowed tongue
Low urine output
Hardened stools