Chapter 16
Fluid and Chemical
Balance
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
1
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.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
2
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
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
3
Average distribution of body fluid
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
4
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:
1. Interstitial fluid (fluid in tissues)
2. Intravascular fluid (the watery plasma,
or serum, portion of blood)
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
5
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
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
6
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
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
7
Assessing a Client’s Fluid Status: Output
 Urine
 Emesis (vomitus)
 Blood loss
 Diarrhea
 Wound or tube drainage
 Aspirated irrigations
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
8
Assessing Fluid Status
 Calibrated containers used to measure liquid
volumes.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
9
Intake and output record
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
10
Common Fluid Imbalances
 Hypovolemia:
 low volume in extracellular fluid compartments If untreated,
hypovolemia results in dehydration

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)

Physical S&S of dehydration:

Acute weight. loss, Oliguria, concentrated urine, sunken eyes,
poor skin turgor, low BP, weak rapid pulse, dizziness.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
11
Common Fluid Imbalances ( cont‘d )
 Hypervolemia:
 Excess water in the intravascular fluid compartment

Edema (excess fluid is distributed to the interstitial space).

Dependent edema: fluid accumulates in dependent areas
of the body (influenced by gravity)
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
12
Common Fluid Imbalances ( cont‘d )
 Third-spacing:
 movement of intravascular fluid to nonvascular
fluid compartments where it becomes trapped and
useless
Peritoneum common place for
fluid build-up
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
13
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
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
14
Intravenous Fluids administration
 Intravenous (IV) fluids are solutions infused into
a client’s vein to:
 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
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
15
Types of Intravenous Solutions
 Isotonic:
 Contains the same concentration of dissolved
substances as normally found in plasma (0.9% saline
(NS), Ringer's lactate )
 Hypotonic:
 Contains fewer dissolved substances than normally
found in plasma (Ex: 0.45% sodium chloride)
 Hypertonic:
 More concentrated than body fluid and draws
cellular and interstitial water into the intravascular
compartment
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
16
IV Solutions
A. Isotonic solutions
B. Hypotonic solutions (cell swelling)
C. Hypertonic solutions (cell shrinkage)
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
17
Venipuncture

Venipuncture
 (accessing the venous system by piercing a vein
with a needle)
 Venipuncture device is inserted in veins of:
 Hand or forearm in adults
 Scalp in child
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
18
Selecting a Venipuncture Site
1. Use veins on the non dominant side.
 this reduces the potential for dislodging the device as a
result of movement and use.
2. Do not use foot and leg veins.
 using foot and leg veins restricts mobility and increases the
potential for blood clots.
3. If possible, do not use a vein on the side of
previous breast surgery or in which vascular
surgery has been performed for kidney dialysis.
 using such veins further compromises circulation and
increases the potential for infection and poor healing.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
19
Selecting a Venipuncture Site (cont'd)
4. Choose a vein in a location unaffected by joint it's
movement.
 a venipuncture device in such a location could become
displaced more easily.
5. Look for a large vein, if a large-gauge needle or
catheter is necessary.
 matching the needle and vein size prevents compromising
circulation.
6. Avoid using veins on the inner surface of the wrist.
 this prevents pain and discomfort.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
20
Selecting a Venipuncture Site (cont'd)
7. Look for a vein proximal to the current site or in the
opposite hand or arm.
 This promotes healing and decreases the risk of fluid
leaking from the vein into the tissue.
8. Feel and look for a fairly straight vein.
 It is easier to thread the device into a straight vein.
9. Do not use a vein that appears inflamed or if the
skin over the area looks impaired in any way.
 Use of such a site creates additional trauma
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
21
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.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
22
Types of Tubing
1. Microdrip (small drops) chamber:

standard volume of 60 drops/mL
2. Macrodrip (large drops) chamber:

usually 15, and 20 drops/mL.
Drop factor (number of drops/mL) is important in calculating
infusion rate when infusion is done by gravity
3.
Filtered tubing:
removes air bubbles, un-dissolved
drugs, bacteria, large substances
Ex: PRBCs, parental nutrition, pediatrics
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
23
Techniques for Infusing Intravenous Solutions
1. Gravity infusion
2. Electronic infusion devices
 Infusion pumps
 Volumetric controllers
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
24
Complications With IV Administration
 Complications associated with the infusion of IV
solutions are :
 Circulatory overload (intravascular volume that
becomes excessive).
 Infiltration (escape of IV fluid into the tissue).
 Phlebitis (inflammation of a vein).
 Thrombus formation (stationary blood clot).
 Pulmonary embolus (blood clot that travels to the lung).
 Infection (growth of microorganisms at the site or within
the blood stream), and
 Air embolism (bubble of air traveling within the vascular
system).
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
25
Infusion Monitoring and Maintenance
 Regulating the Infusion Rate
 The nurse is responsible for calculating, regulating,
and maintaining the rate of infusion according to the
physician's order.
 If an infusion device is used, the electronic equipment
is programmed in milliliters per hour.
 If the solution is infused without an electronic infusion
device (i.e., by gravity), the rate is calculated in drops
(gtt) per minute.
 Formulas for calculating infusion rates are provided in
Box 16-5.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
26
calculating flow rate
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
27
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
28
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
29
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
30
Caring for the Site
 Because the venipuncture is a type of wound, it
is important to inspect the site routinely.
 The nurse documents its appearance in the
client's record.
 A common practice is to change the dressing
over the venipuncture site every 24 to 72 hours
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
31
Replacing Equipment
 Solutions are replaced when they finish infusing
or every 24 hours, whichever occurs first (Skill
16-4).
 IV tubing is changed every 72 hours, depending
on agency policy, with some exceptions.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
32
Blood Administration
 Blood is collected, stored, and checked for safety and
compatibility before it is administered as a transfusion.
 Blood Collection and Storage
 Blood donors are screened to ensure they are healthy and
will not be endangered by the temporary loss in blood
volume. Refrigerated blood can be stored for 21 to 35 days,
after which it is discarded.
 Blood Safety
 Once collected, the donated blood is tested for syphilis, hepatitis,
and human immunodeficiency virus (HIV) antibodies to exclude
administering blood that may transmit these blood-borne
diseases.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
33
Blood Compatibility
 Antigens determine the characteristic blood
group—A, B, AB, and O—and Rh factor. Rh
positive means the protein is present; Rh
negative means the protein is absent.
 Before donated blood is administered, the blood
of the potential recipient is typed and mixed, or
cross-matched, with a sample of the stored blood
to determine whether the two are compatible. To
avoid an incompatibility reaction, it is best to
administer the same blood group and Rh factor.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
34
Blood Transfusion
 Before administering blood, the nurse
obtains and documents the client's
vital signs to provide a baseline for
comparison should the client have a
transfusion reaction.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
35
Blood Transfusion Equipment
 Catheter or Needle Gauge
 it generally is infused through a 16- to 20-gauge—
preferably an 18-gauge—catheter or needle.
 Blood Transfusion Tubing
 Blood is administered through tubing referred to as a
Y-set (Fig. 16-20).
 The normal saline always is administered before
the blood is hung and follows after the blood has
been infused. It also is used during the infusion if
the client has a transfusion reaction
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
36
Figure 16-20 • Blood transfusion tubing.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
37
Transfusion Reactions
 Usually occur within first 5-15 minutes of the
transfusion
 Staff remains with client for the 1st 15 minutes
 Incompatibility
 Febrile
 Septic
 Allergic
 Moderate chilling
 Overload
 Hypocalcaemia
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
38
Total Parenteral Nutrition
 Total parenteral nutrition (TPN; hypertonic solution of
nutrients designed to meet almost all caloric and nutritional
needs) is preferred for clients who are severely malnourished
or may not be able to consume food or liquids for a long
period.
 Because TPN solutions are extremely concentrated, they
must be delivered to an area where they are diluted in a
fairly large volume of blood. This excludes peripheral veins.
 TPN solutions are infused through a catheter inserted into
the subclavian or jugular vein; the tip terminates in the
superior vena cava.
 This type of a catheter is referred to as a central venous
catheter
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
39
Figure 16-21 • Central venous
catheter inserted into the subclavian
vein and threaded into the superior
vena cava.
Second semester 15 - 16
Bader A. EL Safadi
BSN , MSc
Fundamental of Nursing - B
Fluid and Chemical Balance
40