FLUID AND

ELECTROLYTES
REPLACEMENT THERAPY
JOHN PAUL N. REGANIT, MSN, LPT, RN
CLINICAL INSTRUCTOR
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WATER OVERVIEW

• Water comprises about

60% -70% of the total body weight
• Varies with
 age
 weight
 gender
• When a person loses more than 10% of his total body
fluids,he can DIE!!!
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GENERAL CONCEPTS

Intake = Output = Fluid Balance

FLUID COMPARTMENTS AGE-RELATED FLUID CHANGES

1. INTRACELLULAR • Full-term baby - 80%
40% of body weight • Lean Adult Male - 60%
2. EXTRACELLULAR • Aged client - 40%
20% of body weight
TWO TYPES
a. INTERSTITIAL (between)
b. INTRAVASCULAR (inside)
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ROUTES OF FLUID LOSS
1. SENSIBLE LOSSES
a. Urination (Urine)
b. Defecation (Feces)
c. Wound drainage (Wound discharges)

2. INSENSIBLE LOSSES
a. Evaporation from skin (Sweat)
b. Respiratory loss from lungs (Exhalation)
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ORGANS OF FLUID LOSS

1. Urine (Kidney) 1,500ml/day

2. Sweat (Skin) 600ml/day
3. Vapor from breath (Lungs) 300ml/day
4. Feces (GI Tract) 100ml/day

Total Fluid Loss 2, 500ml/day

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CAUSES OF INCREASED CAUSES OF INCREASED
WATER LOSS WATER GAIN
a. Fever a. Increased sodium intake
b. Diarrhea b. Increased sodium retention
c. Diaphoresis c. Excessive intake of water
d. Vomiting d. Excess secretion of ADH
e. Gastric suctioning
f. Tachypnea
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IV FLUIDS AND SOLUTIONS GUIDE
INTRAVENOUS FLUIDS / Intravenous Solutions (IVF)
are supplemental fluids used in intravenous therapy to restore or maintain
normal fluid volume and electrolyte balance when the oral route is not
possible
IV FLUID THERAPY
is an efficient and effective way of supplying fluids directly into the
intravascular fluid compartment, in replacing electrolyte losses, and in
administering medications and blood products.
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TYPES OF IV FLUIDS
There are different types of IV fluids and different ways on how to classify them.
The most common way to categorize IV fluids is based on their TONICITY:
1. ISOTONIC.
solutions that have the same concentration of solutes as
blood plasma.
2. HYPOTONIC.
swell/burst
have lesser concentration of solutes than plasma.
3. HYPERTONIC.
have greater concentration of solutes than plasma.

the cell will shrink

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TYPES OF IV FLUIDS
IV solutions can also be classified based on their PURPOSE:
1. NUTRIENT SOLUTIONS
May contain dextrose, glucose, and levulose to make up the carbohydrate
component – and water. Water is supplied for fluid requirements and
energy carbohydrate for calories and energy. Nutrient solutions are useful in
preventing dehydration and ketosis.
Ex: D5W, D5NSS. dextrose-sugar
2. ELECTROLYTE SOLUTIONS
Na, K, Cl, Mg, Ca
Contains varying amounts of cations and anions that are used to replace
fluid and electrolytes for clients with continuing losses.
Ex: 0.9 NaCl, Ringer’s Solution, and LRS.
electrolytes
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TYPES OF IV FLUIDS
IV solutions can also be classified based on their PURPOSE:
3. ALKALINIZING SOLUTIONS
Are administered to treat metabolic acidosis.
Examples: LRS.
4. ACIDIFYING SOLUTIONS.
Are used to counteract metabolic alkalosis.
D51/2NS, 0.9 NaCl.
5. VOLUME EXPANDERS.
Are solutions used to increase the blood volume after a severe blood loss,
or loss of plasma.
Examples: dextran, human albumin, and plasma.
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ISOTONIC IV FLUIDS PNSS
0.9% NaCl (NORMAL SALINE SOLUTION, NSS)
• is a crystalloid isotonic IV fluid that contains water,
sodium (154 mEq/L), and chloride (154 mEq/L).
• It has an osmolality of 308 mOsm/L and gives no
calories.

• It is called normal saline solution because the percentage of sodium

chloride dissolved in the solution is similar to the usual concentration of
sodium and chloride in the intravascular space.
• Normal saline is the isotonic solution of choice for expanding the
extracellular fluid (ECF) volume because it does not enter the
intracellular fluid (ICF).
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ISOTONIC IV FLUIDS
0.9% NaCl (NORMAL SALINE SOLUTION, NSS)
• It is administered to correct extracellular fluid
volume deficit because it remains within the ECF.
• Normal saline is the IV fluid used alongside the
administration of blood products.

• It is also used to replace large sodium losses such as in burn injuries

and trauma.
• It should not be used for heart failure, pulmonary edema, and renal
impairment, or conditions that cause sodium retention as it may risk fluid
volume overload.
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ISOTONIC IV FLUIDS
Dextrose 5% in Water (D5W)
• a crystalloid isotonic IV fluid with a serum osmolality
of 252 mOsm/L.
• initially an isotonic solution and provides free water
when dextrose is metabolized (making it a
hypotonic solution), expanding the ECF and the
ICF.
• It is administered to supply water and to correct an increase in serum osmolality.
• A liter of D5W provides fewer than 200 kcal and contains 50g of glucose. It should not
be used for fluid resuscitation because hyperglycemia can result.
• It should also be avoided to be used in clients at risk for increased intracranial
pressure as it can cause cerebral edema.

EXPAND CELLS
sugar enter brain
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ISOTONIC IV FLUIDS sugar electrolytes
Lactated Ringer’s 5% Dextrose in Water (D5LRS)
• Ringer’s Lactate or Hartmann solution
• is a crystalloid isotonic IV fluid designed to be the
b5-145 near-physiological solution of balanced electrolytes.
It contains 130 mEq/L of sodium, 4 mEq/L of
potassium, 3 mEq/L of calcium, and 109 mEq/L of
chloride.
• It also contains bicarbonate precursors to prevent acidosis.
• It does not provide calories or magnesium and has limited potassium
replacement.
• It is the most physiologically adaptable fluid because its electrolyte
content is most closely related to the composition of the body’s blood
serum and plasma.
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ISOTONIC IV FLUIDS
Lactated Ringer’s 5% Dextrose in Water (D5LRS)
• is used to correct dehydration, sodium depletion,
and replace GI tract fluid losses.
• used in fluid losses due to burns, fistula drainage,
and trauma.
• It is the choice for first-line fluid resuscitation for
certain patients.
• It is often administered to patients with metabolic acidosis.
• is metabolized in the liver, which converts the lactate to bicarbonate,
therefore, it should not be given to patients who cannot metabolize
lactate/ lactate (e.g., liver disease, lactic acidosis).
lactate acid • It should be used in caution for patients with heart failure and
renal failure.
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ISOTONIC IV FLUIDS
Ringer’s Solution
• another isotonic IV solution that has content similar
to Lactated Ringer’s Solution but does not contain
lactate.
• Indications are the same for Lactated Ringer’s but
without the contraindications related to lactate.
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NURSING CONSIDERATIONS FOR ISOTONIC SOLUTIONS
1. DOCUMENT BASELINE DATA.
Before infusion, assess the patient’s vital signs, edema status, lung
sounds, and heart sounds. Continue monitoring during and after the infusion.
2. OBSERVE FOR SIGNS OF FLUID OVERLOAD.
Look for signs of hypervolemia such as hypertension, bounding pulse,
pulmonary crackles, dyspnea, shortness of breath, peripheral edema, jugular
venous distention, and extra heart sounds.
3. MONITOR MANIFESTATIONS OF CONTINUED HYPOVOLEMIA.
Look for signs that indicate continued hypovolemia such as, decreased urine
output, poor skin turgor, tachycardia, weak pulse, and hypotension.
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NURSING CONSIDERATIONS FOR ISOTONIC SOLUTIONS
4. PREVENT HYPERVOLEMIA.
Patients being treated for hypovolemia can quickly develop fluid overload
following rapid or over infusion of isotonic IV fluids.
5. ELEVATE THE HEAD OF THE BED AT 35 TO 45 DEGREES
Unless contraindicated, position the client in semi-Fowler’s position.
6. ELEVATE THE PATIENT’S LEGS.
If edema is present, elevate the legs of the patient to promote venous return.
7. EDUCATE PATIENTS AND FAMILIES.
Teach patients and families to recognize signs and symptoms of fluid volume
overload. Instruct patients to notify their nurse if they have trouble breathing or
notice any swelling.
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NURSING CONSIDERATIONS FOR ISOTONIC SOLUTIONS
8. CLOSE MONITORING FOR PATIENTS WITH HEART FAILURE.
Because isotonic fluids expand the intravascular space, patients with
hypertension and heart failure should be carefully monitored for signs of fluid
overload.
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HYPOTONIC IV FLUIDS
• have a lower osmolality and contain fewer solutes than plasma.
• They cause fluid shifts from the ECF into the ICF to achieve
homeostasis, therefore, causing cells to swell and may even rupture.
• IV solutions are considered hypotonic if the total electrolyte content
is less than 250 mEq/L.
• Hypotonic IV fluids are usually used to provide free water for
excretion of body wastes, treat cellular dehydration, and replace the
cellular fluid.
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HYPOTONIC IV FLUIDS
0.45% Sodium Chloride (0.45% NaCl)
• also known as half-strength normal saline
• is a hypotonic IV solution used for replacing water
in patients who have hypovolemia with
hypernatremia.
• Excess use may lead to hyponatremia due to the
dilution of sodium, especially in patients who are
prone to water retention.
• It has an osmolality of 154 mOsm/L and contains 77 mEq/L sodium and
chloride.
• Hypotonic sodium solutions are used to treat hypernatremia and other
hyperosmolar conditions.
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HYPOTONIC IV FLUIDS
0.33% Sodium Chloride (0.33% NaCl)
• is used to allow kidneys to retain the needed
amounts of water and is typically administered with
dextrose to increase tonicity.
• It should be used in caution for patients with heart
failure and renal insufficiency.
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HYPOTONIC IV FLUIDS
0.225% Sodium Chloride (0.225% NaCl)
• is often used as a maintenance fluid for pediatric
patients as it is the most hypotonic IV fluid available
at 77 mOsm/L.
• Used together with dextrose.
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HYPOTONIC IV FLUIDS
2.5% Dextrose in Water (D2.5W)
• Another hypotonic IV solution commonly used
• This solution is used to treat dehydration and
decreased the levels of sodium and potassium.
• It should not be administered with blood products
as it can cause hemolysis of red blood cells.
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NURSING CONSIDERATIONS FOR HYPOTONIC SOLUTIONS
1. DOCUMENT BASELINE DATA.
Before infusion, assess the patient’s vital signs, edema status, lung sounds, and
heart sounds. Continue monitoring during and after the infusion.
2. DO NOT ADMINISTER IN CONTRAINDICATED CONDITIONS.
Hypotonic solutions may exacerbate existing hypovolemia and hypotension
causing cardiovascular collapse. Avoid use in patients with liver disease,
trauma, or burns.
3. RISK FOR INCREASED INTRACRANIAL PRESSURE (IICP)
Should not be given to patients with risk for IICP as the fluid shift may cause
cerebral edema (remember: hypotonic solutions make cells swell).
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NURSING CONSIDERATIONS FOR HYPOTONIC SOLUTIONS
4. MONITOR FOR MANIFESTATIONS OF FLUID VOLUME DEFICIT.
Signs and symptoms include confusion in older adults. Instruct patients to inform
the nurse if they feel dizzy.
5. WARNING ON EXCESSIVE INFUSION.
Excessive infusion of hypotonic IV fluids can lead to intravascular fluid depletion,
decreased blood pressure, cellular edema, and cell damage.
6. DO NOT ADMINISTER ALONG WITH BLOOD PRODUCTS.
Most hypotonic solutions can cause hemolysis of red blood cells especially
during rapid infusion of the solution.
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HYPERTONIC SODIUM CHLORIDE IV FLUIDS
• have a greater concentration of solutes (375 mEq/L and greater) than
plasma and cause fluids to move out of the cells and into the ECF in
order to normalize the concentration of particles between two
compartments.
• This effect causes cells to shrink and may disrupt their function.
• They are also known as volume expanders as they draw water out of
the intracellular space, increasing extracellular fluid volume.
• contain a higher concentration of sodium and chloride than normally
contained in plasma.
• Infusion of hypertonic sodium chloride solution shifts fluids from the
intracellular space into the intravascular and interstitial spaces.
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HYPERTONIC SODIUM CHLORIDE IV FLUIDS
• Hypertonic sodium chloride IV solutions are
available in the following forms and strengths:

a. 3% sodium chloride (3% NaCl) containing

513 mEq/L of sodium and chloride with an
osmolality of 1030 mOsm/L.
b. 5% sodium chloride (5% NaCl) containing
855 mEq/L of sodium and chloride with an
osmolality of 1710 mOsm/L.
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HYPERTONIC SODIUM CHLORIDE IV FLUIDS
• are used in the acute treatment of sodium deficiency (severe
hyponatremia) and should be used only in critical situations to treat
hyponatremia.
• They need to be infused at a very low rate to avoid the risk of overload
and pulmonary edema.
• If administered in large quantities and rapidly, they may cause an
extracellular volume excess and precipitate circulatory overload and
dehydration.
• Therefore, they should be administered cautiously and usually only when
the serum osmolality has decreased to critically low levels.
• Some patients may need diuretic therapy to assist in fluid excretion.
• It is also used in patients with cerebral edema.
spiron-lactine=
potassium experium
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HYPERTONIC DEXTROSE SOLUTIONS
• Isotonic solutions that contain 5% dextrose (e.g., D5NSS, D5LRS) are
slightly hypertonic since they exceed the total osmolality of the ECF.
However, dextrose is quickly metabolized and only the isotonic solution
remains. Therefore, any effect on the ICF is temporary.
• Hypertonic dextrose solutions are used to provide kilocalories for the
patient in the short term.
• Higher concentrations of dextrose (i.e., D50W) are strong hypertonic
solutions and must be administered into central veins so that they can
be diluted by rapid blood flow.
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HYPERTONIC DEXTROSE SOLUTIONS
Dextrose 10% in Water (D10W)
• is an hypertonic IV solution used in the treatment
of ketosis of starvation and provides calories
(380 kcal/L), free water, and no electrolytes.
• It should be administered using a central line if
possible and should not be infused using the
same line as blood products as it can cause RBC
hemolysis.
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HYPERTONIC DEXTROSE SOLUTIONS
Dextrose 20% in Water (D20W)
• Dextrose 20% in Water (D20W) is hypertonic IV
solution an osmotic diuretic that causes fluid
shifts between various compartments to promote
diuresis.
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HYPERTONIC DEXTROSE SOLUTIONS
Dextrose 50% in Water (D50W)
• Another hypertonic IV solution used commonly
• is used to treat severe hypoglycemia and is
administered rapidly via IV bolus.
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NURSING CONSIDERATIONS FOR HYPERTONIC SOLUTIONS
1.DOCUMENT BASELINE DATA.
Before infusion, assess the patient’s vital signs, edema status, lung sounds, and
heart sounds. Continue monitoring during and after the infusion.
2. WATCH FOR SIGNS OF HYPERVOLEMIA.
Since hypertonic solutions move fluid from the ICF to the ECF, they increase the
extracellular fluid volume and increases the risk for hypervolemia.
Look for signs of swelling in arms, legs, face, shortness of breath, high blood
pressure, and discomfort in the body (e.g., headache, cramping).
3. MONITOR AND OBSERVE THE PATIENT DURING ADMINISTRATION.
Hypertonic solutions should be administered only in high acuity areas with constant
nursing surveillance for potential complications.
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NURSING CONSIDERATIONS FOR HYPERTONIC SOLUTIONS
4. VERIFY ORDER
Prescription for hypertonic solutions should state the specific hypertonic fluid to be
infused, the total volume to be infused, the infusion rate and the length of time to
continue the infusion.
5. ASSESS HEALTH HISTORY.
Patients with kidney or heart disease and those who are dehydrated should not
receive hypertonic IV fluids. These solutions can affect renal filtration mechanisms
and can easily cause hypervolemia to patients with renal or heart problems.
6. PREVENT FLUID OVERLOAD.
Ensure that administration of hypertonic fluids does not precipitate fluid volume
excess or overload.
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NURSING CONSIDERATIONS FOR HYPERTONIC SOLUTIONS
7. DO NOT ADMINISTER PERIPHERALLY.
Hypertonic solutions can cause irritation and damage to the blood vessel and
should be administered through a central vascular access device inserted into a
central vein.
8. MONITOR BLOOD GLUCOSE CLOSELY.
Rapid infusion of hypertonic dextrose solutions can cause hyperglycemia. Use with
caution for patients with diabetes mellitus.
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COLLOIDS
• Colloids contain large molecules that do not pass through
semipermeable membranes.
• Colloids are IV fluids that contain solutes of high molecular weight,
technically, they are hypertonic solutions, which when infused, exert an
osmotic pull of fluids from interstitial and extracellular spaces.

• They are useful for expanding the intravascular volume and raising blood
pressure.
• Colloids are indicated for patients in malnourished states and patients who
cannot tolerate large infusions of fluid.
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COLLOIDS
Human Albumin
• is a solution derived from plasma.
• It has two strengths: 5% ALBUMIN AND 25%
ALBUMIN.
a. 5% Albumin is a solution derived from plasma
and is a commonly utilized colloid solution.
• It is used to increase the circulating volume and
restore protein levels in conditions such as
burns, pancreatitis, and plasma loss through
trauma
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COLLOIDS
Human Albumin
b. 25% Albumin is used together with sodium and
water restriction to reduce excessive edema.
• They are considered blood transfusion products
and uses the same protocols and nursing
precautions when administering albumin.
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COLLOIDS
Human Albumin
• The use of albumin is contraindicated in patients
with the following conditions: severe anemia,
heart failure, or known sensitivity to albumin.
• Additionally, angiotensin-converting enzyme
inhibitors should be withheld for at least 24 hours
before administering albumin because of the risk
of atypical reactions, such as hypotension and
flushing.
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COLLOIDS
Dextrans
• Dextrans are polysaccharides that act as
colloids.
• Dextran interferes with blood crossmatching, so
draw the patient’s blood before administering
dextran, if crossmatching is anticipated.
• They are available in two types:
a. low-molecular-weight dextrans (LMWD)
b. b. high-molecular-weight dextrans (HMWD).
• They are available in either (1) saline or (2) glucose solutions.
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COLLOIDS
Dextrans
a. Low-molecular-weight Dextrans (LMWD)
• contains polysaccharide molecules that behave like
colloids with an average molecular weight of 40,000
(Dextran 40).
• is used to improve the microcirculation in patients with poor
peripheral circulation.
• They contain no electrolytes and are used to treat shock related to vascular volume loss
(e.g., burns, hemorrhage, trauma, or surgery).
• On certain surgical procedures, LMWDs are used to prevent venous thromboembolism.
They are contraindicated in patients with thrombocytopenia, hypofibrinogenemia, and
hypersensitivity to dextran.
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COLLOIDS
Dextrans
b. High-molecular-weight Dextrans (HMWD)
• contains polysaccharide molecules with an average
molecular weight of 70,000 (Dextran 70) or 75,000
(Dextran 75).
• used for patients with hypovolemia and hypotension.
• They are contraindicated in patients with hemorrhagic
shock.
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COLLOIDS
Etherified Starch
These solutions are derived from starch and are used to
increase intravascular fluid but can interfere with normal
coagulation.
Examples include EloHAES, HyperHAES, and Voluven.
Gelatin
Gelatins have lower molecular weight than dextrans and
therefore remain in the circulation for a shorter period of time.
Plasma Protein Fraction (PPF)
Plasma Protein Fraction is a solution that is also prepared from
plasma, and like albumin, is heated before infusion.
It is recommended to infuse slowly to increase circulating
volume.
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NURSING CONSIDERATIONS FOR COLLOID SOLUTIONS
1. ASSESS ALLERGY HISTORY.
Most colloids can cause allergic reactions, although rare, so take a careful allergy
history, asking specifically if they’ve ever had a reaction to an IV infusion before.
2. USE A LARGE-BORE NEEDLE (18-GAUGE).
A larger needle is needed when administering colloid solutions.
3. DOCUMENT BASELINE DATA.
Before infusion, assess the patient’s vital signs, edema status, lung sounds, and
heart sounds. Continue monitoring during and after the infusion .
4. MONITOR THE PATIENT’S RESPONSE.
Monitor intake and output closely for signs of hypervolemia, hypertension, dyspnea,
crackles in the lungs, and edema.
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NURSING CONSIDERATIONS FOR COLLOID SOLUTIONS
5. MONITOR COAGULATION INDEXES.
Colloid solutions can interfere with platelet function and increase bleeding times, so
monitor the patient’s coagulation indexes.
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REFERENCES
• Berman, A. et al., (2015). Kozier & Erbs Fundamentals Of Nursing. Eighth Ed.,
New Jersey, USA
• Craven, R. et al., (2005). Lippincott & Williams Fundamentals Of Nursing. Human
Health And Function. Fourth Ed.
• Cheever, K. et al (2017). Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, Tenth Ed., Pensylvannia, USA
• Dougherty, L., & Lamb, J. (Eds.) (2009). Intravenous Therapy In Nursing
Practice, London, UK
• Nursing Crib
• Nurses Lab
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JOHN PAUL N. REGANIT, MSN, LPT, RN
CLINICAL INSTRUCTOR