Basics of acid-base balance

Before assessing a patients acid-base balance, you need to understand how the H+ affects
acids, bases, and pH.

An acid is a substance that can donate H+ to a base. Examples include hydrochloric

acid, nitric acid, ammonium ion, lactic acid, acetic acid, and carbonic acid (H 2CO3).

A base is a substance that can accept or bind H+. Examples include ammonia,
lactate, acetate, and bicarbonate (HCO 3-).

pH reflects the overall H+ concentration in body fluids. The higher the number of H+
in the blood, the lower the pH; and the lower the number of H+, the higher the pH.

A solution containing more base than acid has fewer H+ and a higher pH. A solution
containing more acid than base has more H+ and a lower pH. The pH of water (H 2O), 7.4, is
considered neutral.
The pH of blood is slightly alkaline and has a normal range of 7.35 to 7.45. For normal
enzyme and cell function and normal metabolism, the bloods pH must remain in this narrow
range. If the blood is acidic, the force of cardiac contractions diminishes. If the blood is
alkaline, neuromuscular function becomes impaired. A blood pH below 6.8 or above 7.8 is
usually fatal.
pH also reflects the balance between the percentage of H+ and the percentage of HCO 3-.
Generally, pH is maintained at a ratio of 20 parts HCO 3- to 1 part H2CO3. (See Fast facts on
acid-base balance by clicking the PDF icon above.)

Regulating acid-base balance

Three regulating systems maintain the bodys pH: chemical buffers, the respiratory system,
and the renal system.

Chemical buffers, substances that combine with excess acids or bases, act immediately to
maintain pH and are the bodys most efficient pH-balancing force. These buffers appear in
blood, intracellular fluid, and extracellular fluid. The main chemical buffers are bicarbonate,
phosphate, and protein.
The second line of defense against acid-base imbalances is the respiratory system. The
lungs regulate carbon dioxide (CO2) in the blood, which combines with H2O to form H2CO3.
Chemoreceptors in the brain sense pH changes and vary the rate and depth of respirations
to regulate CO2 levels. Faster, deeper breathing eliminates CO2 from the lungs, and less
H2CO3 is formed, so pH rises. Alternatively, slower, shallower breathing reduces
CO2 excretion, so pH falls.
The partial pressure of arterial CO2 (Paco2) level reflects the level of CO2 in the blood.
Normal Paco2 is 35 to 45 mm Hg. A higher CO2 level indicates hypoventilation from shallow
breathing. A lower Paco2 level indicates hyperventilation. The respiratory system, which can
handle twice as many acids and bases as the buffer systems, responds in minutes, but
compensation is temporary. Long-term adjustments require the renal system.
The renal system maintains acid-base balance by absorbing or excreting acids and bases.
Also, the kidneys can produce HCO3- to replenish lost supplies. The normal HCO3- level is
22 to 26 mEq/L. When blood is acidic, the kidneys reabsorb HCO 3- and excrete H+. When
blood is alkaline, the kidneys excrete HCO3- and retain H+. Unlike the lungs, the kidneys
may take 24 hours before starting to restore normal pH.

Compensating for imbalances

The two disorders of acid-base balance are acidosis and alkalosis. In acidosis, the blood
has too much acid (or too little base). In alkalosis, the blood has too much base (or too little
acid). The cause of these acid-base disorders is either respiratory or metabolic. If the
respiratory system is responsible, youll detect it by reviewing Paco 2 or serum CO2 levels. If
the metabolic system is responsible, youll detect it by reviewing serum HCO 3- levels.
To regain acid-base balance, the lungs may respond to a metabolic disorder, and the
kidneys may respond to a respiratory disorder. If pH remains abnormal, the respiratory or
metabolic response is called partial compensation. If the pH returns to normal, the response
is called complete compensation. Keep in mind that the respiratory or renal system will

never overcompensate. A compensatory mechanism wont make an acidotic patient

alkalotic or an alkalotic patient acidotic.

Understanding acidosis and alkalosis

Caused by hypoventilation, respiratory acidosis develops when the lungs dont adequately
eliminate CO2. The hypoventilation may result from diseases that severely affect the lungs,
diseases of the nerves and muscles of the chest that impair the mechanics of breathing, or
drugs that slow a patients respirations. Respiratory acidosis causes a pH below 7.35 and a
Paco2 above 45 mm Hg. HCO3- is normal. (See Causes of acid-base imbalances at a
glance by clicking the PDF icon above.)
Caused by hyperventilation, respiratory alkalosis develops when the lungs eliminate too
much CO2. The most common cause of hyperventilation is anxiety. Respiratory alkalosis
causes a pH above 7.45 and a Paco2 below 35 mm Hg. HCO3- is normal.
Metabolic acidosis may result from:

ingestion of an acidic substance or a substance that can be metabolized to an acid

production of excess acid

an inability of the kidneys to excrete normal amounts of acid

a loss of base.

Metabolic acidosis causes a HCO3- below 22 mEq/L and a pH below 7.35. Paco2 is normal.
Metabolic alkalosis may result from:

loss of stomach acid

an excess loss of sodium or potassium

a renal loss of H+

a gain of base.

Metabolic alkalosis causes a HCO3- above 26 mEq/L and a pH above 7.45. Paco2 is normal.

ABG analysis in four steps

ABG analysis is a diagnostic test that helps you assess the effectiveness of your patients
ventilation and acid-base balance. The results also help you monitor your patients response
to treatment. ABG analysis provides several test results, but only three are essential for
evaluating acid-base balance: pH, Paco2, and HCO3-. Memorize these normal values for
adults:

pH: 7.35 to 7.45

Paco2: 35 to 45 mm Hg

HCO3-: 22 to 26 mEq/L.

Remember, the key to interpreting ABG values at the bedside is consistency. Follow these
four simple steps every time:

Step 1. List the results for the three essential values: pH, Paco 2, and HCO3-.

Step 2. Compare them with normal values. If a result indicates excessive acid, write
an
A next to it. If a result indicates excessive base, write a
B next to it. And if a result indicates a normal balance, write an N next to it. The pH
will tell you whether the patient has acidosis or alkalosis.

Step 3. If youve written the same letter for two or three results, circle them. If you
circle pH and Paco2, your patient has a respiratory disorder. If you circle pH and
HCO3-, your patient has a metabolic disorder. If you circle all three results, your
patient has a combined respiratory and metabolic acid-base disturbance.
(See Interpreting arterial blood gas values by clicking the PDF icon above.)

Step 4. To check for compensation, look at the result you didnt circle. If it has moved
from the normal value in the opposite direction of those circled, compensation is
occurring. If the value remains in the normal range, no compensation has occurred.
Once compensation is complete, the pH will return to normal.

Keep in mind that several factors can make ABG results inaccurate:

using improper technique to draw the arterial blood sample

drawing venous blood instead of arterial blood

drawing an ABG sample within 20 minutes of a procedure, such as suctioning or

administering respiratory treatment

allowing air bubbles in the sample

delaying transport of the sample to the lab.

Nursing implications
ABG values provide important information about your patients condition. But never
underestimate the importance of your clinical assessment and judgment. As a nurse, you
are the most important advocate for your patients because you are constantly at the
bedside, monitoring, assessing, intervening, and reevaluating.
Your role begins with identifying patients at risk for acid-base disturbances, including those
who have or are at risk for:

significant electrolyte imbalances

net gain or loss of acids

net gain or loss of bases

ventilation abnormalities

abnormal kidney function.

Assess patients carefully to identify early clues of acid-base disturbances. Consider what
your patients vital signs are telling you. Count your patients respirations for a full minute.
What are the rate and the depth? Are they clues to an impending or underlying respiratory
or metabolic problem? What is your patients level of consciousness? Confusion can be an
early sign of an acid-base disturbance. Correlate your patients fluid balance and creatinine
levels with kidney function. Always correlate your assessment findings with your patients
diagnosis. Do they match? Or is some clue pointing in a different direction? Be sure to
double-check the implications and adverse effects of all drugs you administer.

Treating acid-base imbalances

Treatment for metabolic acidosis focuses on correcting the underlying cause. For a diabetic
patient, treatment consists of controlling blood glucose and insulin levels. In a case of
poisoning, treatment focuses on eliminating the toxin from the blood. Correcting the
underlying cause of sepsis may include antibiotic therapy, fluid administration, and surgery.
You may also treat the acidosis directly. If its mild, administering I.V. fluid may correct the
problem. If acidosis is severe, you may give bicarbonate I.V., as prescribed.

Treatment for metabolic alkalosis also focuses on the underlying cause. Frequently, an
electrolyte imbalance causes this disorder, so treatment consists of replacing fluid, sodium,
and potassium.
The treatment goal for respiratory acidosis is to improve ventilation. Expect to administer
drugs such as bronchodilators to improve breathing and, in severe cases, to use
mechanical ventilation. Maintain good pulmonary hygiene.
Usually, the only treatment goal for respiratory alkalosis is to slow the breathing rate. If
anxiety is the cause, encourage the patient to slow his or her breathing. Some patients may
need an anxiolytic. If pain is causing rapid, shallow breathing, provide pain relief. Breathing
into a paper bag allows a patient to rebreathe CO 2, raising the level of CO2 in the blood.

Practice makes perfect

Use the case histories below to test your acid-base knowledge with some examples. Read
each history and try to determine the cause of the signs and symptoms. Then, read the
interpretation section to see how well you did. (See Beyond pH, Paco2, and HCO3- by
clicking the PDF icon above.)

Case history 1
Mary Barker, 34, comes to the emergency department (ED) with acute shortness of breath
and pain on her right side. She smokes one pack of cigarettes a day and recently started
taking birth control pills. Her blood pressure is 140/80 mm Hg; her pulse is 110
beats/minute; and her respiratory rate is 44 breaths/minute. Her ABG values are as follows:

pH: 7.50

Paco2: 29 mm Hg

Partial pressure of arterial oxygen (Pao2): 64 mm Hg

HCO3-: 24 mm Hg

Oxygen saturation (SaO2): 86%.

Interpretation: These ABG values reveal respiratory alkalosis without compensation. The
patients pH and Paco2 are alkalotic, and her HCO3- is normal, indicating no compensation.
You would administer oxygen (O2) therapy, as ordered, to increase SaO2 to more than 95%;
encourage the patient to breathe slowly and regularly to decrease CO 2 loss; administer an
analgesic, as ordered, to ease pain; and support her emotionally to decrease anxiety.
Based on the clues, the probable underlying cause is pulmonary embolism.

Case history 2
John Stewart, 22, is brought to the ED for an overdose of a tricyclic antidepressant. Hes
unconscious and has a respiratory rate of 5 to 8 breaths/minute. His ABG values are as
follows:

pH: 7.25

Paco2: 61 mm Hg

Paco2: 76 mm Hg

HCO3-: 26 mm Hg

SaO2: 89%.

Interpretation: These ABG values reveal respiratory acidosis without compensation. The
patients pH and Paco2 are acidotic, and his HCO 3- is normal, indicating no compensation.
You would administer O2, as ordered. The patient may be intubated to protect his airway
and placed on a mechanical ventilator. You would also treat the underlying cause by
performing gastric lavage and administering activated charcoal. This patients condition may
progress to metabolic acidosis. If so, you would give sodium bicarbonate to reverse the
acidosis.

Case history 3
Steve Burr, 38, has type 1 diabetes. He hasnt been feeling well for the last 3 days and
hasnt eaten or injected his insulin. Hes confused and lethargic. His respiratory rate is 32
breaths/minute, and his breath has a fruity odor. His serum glucose level is 620 mg/dL.
While receiving 40% O2, his ABG values are:

pH: 7.15

Paco2: 30 mm Hg

Paco2: 130 mm Hg

HCO3-: 10 mm Hg

SaO2: 94%.

Interpretation: These ABG values reveal metabolic acidosis with partial respiratory
compensation. The patients pH and HCO3- indicate acidosis. His Paco2 is lower than
normal, reflecting the lungs attempt to compensate. Because pH is abnormal, you know
compensation isnt complete.

ABG values only

Try interpreting this set of ABG values without a clinical scenario:

pH: 7.49

Paco2: 40 mm Hg

Paco2: 85 mm Hg

HCO3-: 29 mm Hg

SaO2: 90%

Interpretation: These values reveal uncompensated metabolic alkalosis. The pH and HCO 3indicate alkalosis. Paco2 is normal, indicating no compensation.
Now, interpret these values:

pH: 7.25

Paco2: 56 mm Hg

Paco2: 80 mm Hg

HCO3-: 15 mm Hg

SaO2 : 93%

Interpretation: These values reveal mixed acidosis. The pH, HCO3-, and Paco2 all indicate
acidosis.

Back in balance
How did you do? Whether you aced this practice quiz or not, remember that integrating your
ABG interpretation skills into your patient assessments takes practice. By becoming more
adept at identifying specific acid-base disorders, you can ensure that patients receive the
appropriate nursing interventions and get back in balance as quickly as possible.
Selected references
Allibone L, Nation N. Guide to regulation of blood gases: part two. Nurs Times.
2006;102(46):48-50.
Ayers P, Warrington L. Diagnosis and treatment of simple acid-base disorders. Nutr Clin
Pract. 2008;23(2):122-127.
Morton P, Fontaine D, Hudak C, Gallo B. Critical Care Nursing: A Holistic Approach. 8th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2004.

Price S, Wilson L. Pathophysiology: Clinical Concepts of Disease Processes. 6th ed. St.
Louis, MO: Mosby; 2003.
Rhoades R, Pflanzer R. Human Physiology. 4th ed. Fort Worth, TX: Saunders College
Publishing; 2003.
Simpson H. Interpretation of arterial blood gases: a clinical guide for nurses. Br J Nurs.
2004;13(9):522-528.
Michelle Fournier is Founder and CEO of A Choice Above in Denver, Colorado, and a
healthcare consultant for ja thomas & Associates in Smyrna, Georgia. The planners
and author of this CNE activity have disclosed no relevant financial relationships
with any commercial companies pertaining to this activity.

I.V. fluids What nurses need to know

Crawford, Ann PhD, RN; Harris, Helene MSN, RN
Free Access

Article Outline

Author Information
Ann Crawford is professor, College of Nursing, at University of Mary Hardin-Baylor in Belton,
Tex. Helene Harris is a clinical educator at Central Texas Veterans Healthcare System in Temple, Tex.
This is the first in a series of articles on fluids and electrolytes.
The authors have disclosed that they have no financial relationships pertaining to this article.
CAN YOU IMAGINE A LIFE without water? Of course not, because water is essential to sustain life.
Likewise, body fluids are vital to maintain normal body functioning.

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The body reacts to internal and environmental changes by adjusting vital functions to keep fluids and
electrolytes in balance, maintaining homeostasis. This article will explore how fluid acts within the body
and discuss when and why various I.V. fluids can be used to maintain homeostasis. Subsequent articles
in this series will discuss specific electrolyte imbalances. Unless otherwise specified, information applies
to adults, not pediatric patients.
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Water water everywhere

Solutions are comprised of fluid (the solvent) and particles (the solute) dissolved in the fluid. Water is the
body's primary fluid and is essential for proper organ system functioning and survival. Although people
can live several weeks without food, they can survive only a few days without water. 1
Water has many functions in the body; for example, it
* serves as the transport system for nutrients, gases, and wastes in and out of the cells.
* facilitates the elimination of wastes through the kidneys, gastrointestinal (GI) tract, skin, and lungs.
* regulates body temperature through evaporation from the skin.

Water is gained and lost from the body every day. For the body to maintain normal function, the intake
and output of fluid should remain fairly equal. We obtain water through drinking fluids and the metabolism
of nutrients obtained from eating foods.2,3
Fluid intake is regulated by the thirst mechanism in the brain. This mechanism is stimulated when blood
fluid volume decreases. Increased osmolality stimulates the thirst center, triggering the impulse to
increase fluid intake.4
Water is lost from the body through the kidneys, GI tract, lungs, and skin. Losses from the kidneys and GI
tract are known as sensible losses because they can be measured. Insensible losses describe water loss
that can't be measured, including losses through the skin from evaporation and through the lungs from
respiration.2
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Two main fluid compartments

Fluids within the body are contained in two basic compartments, intracellular and extracellular. Cell
membranes and capillary walls separate the two fluid compartments. See Two basic fluid compartments.
The intracellular fluid compartment, which consists of fluid contained within all of our body cells, is the
larger of the two compartments. The extracellular fluid compartment contains all the fluids outside the
cells and is further divided into two major subcomponents: intravascular fluid contained in blood vessels
and interstitial fluid found in the tissue spaces. The intracellular, intravascular, and interstitial spaces are
the major fluid compartments in the body.
A third category of the extracellular fluid compartment is the transcellular compartment, which includes
cerebrospinal fluid and fluid contained in body spaces such as the pleural cavity and joint spaces.
Because transcellular fluids don't normally contribute significantly to fluid balance, they're beyond the
scope of this article.1,2
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How much of you is water?

The amount of water in the body varies depending on age, gender, and body build. In nonobese adults,
intracellular fluid constitutes approximately 40% of body weight, and extracellular fluid, 20%. 1,4(See How
body fluid is distributed.)
Lean body muscle mass is rich in water, while adipose tissue has a lower percentage of water content.
Because of this, someone who's overweight or obese has a lower percentage of water overall compared
with someone who's lean and muscular. Similarly, women typically have a lower percentage of total body
water than men due to a higher percentage of body fat. Older adults tend to have a lower concentration of
water overall, due to an age-related decrease in muscle mass. Conversely, children tend to have a higher
percentage of water weightas much as 80% in a full-term neonate. 1,4
Fluids don't remain static within body compartments; instead, they move continuously among them to
maintain homeostasis. Cell membranes are semipermeable, meaning they allow fluid and some solutes
(particles dissolved in a solution) to pass through.

Figure. Two basic fl...

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Fluids and electrolytes move between compartments via passive and active transport. Passive transport
occurs when no energy is required to cause a shift in fluid and electrolytes. Diffusion, osmosis, and
filtration are examples of passive transport mechanisms that cause body fluid and electrolyte movement. 2
Osmolality and osmolarity are two similar terms that are often confused. Osmolality, which is usually used
to describe fluids inside the body, refers to the solute concentration in fluid by weight: the number of
milliosmols (mOsm) in a kilogram (kg) of solution. Osmolarity refers to the solute concentration in fluid by
number of mOsm per liter (L) of solution. Because 1 L of water weighs 1 kg, the normal ranges are the
same and the terms are often used interchangeably.
Changes in the level of solute concentration influence the movement of water between the fluid
compartments. The normal osmolality for plasma and other body fluids varies from 270 to 300 mOsm/L.
Optimal body function occurs when the osmolality of fluids in all the body compartments is close to 300
mOsm/L. When body fluids are fairly equivalent in this particle concentration, they're said to be isotonic.
Fluids with osmolalities less than 270 mOsm/L are hypotonic in comparison with isotonic fluids, and fluids
with osmolalities greater than 300 mOsm/L are hypertonic. 2 Tonicity of I.V. fluids will be discussed in detail
later in this article.
Through the use of mechanisms such as thirst, the renin-angiotensin-aldosterone system, antidiuretic
hormone, and atrial natriuretic peptide, the body works to maintain appropriate fluid and electrolyte levels
and to prevent imbalances within the body. When an imbalance occurs, you must be able to identify the
cause of the problem and monitor the patient during treatment.
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Crystalloids vs. colloids

One of the methods for treating fluid and electrolyte alterations is the infusion of I.V. solutions, which have
distinctive differences in composition that affect how the body reacts to and utilizes them. When
administering I.V. therapy, you need to understand the nature of the solution being initiated and how it will
affect your patient's condition.
I.V. solutions for fluid replacement may be placed in two general categories: colloids and
crystalloids. Colloids contain large molecules that don't pass through semipermeable membranes. When
infused, they remain in the intravascular compartment and expand intravascular volume by drawing fluid
from extravascular spaces via their higher oncotic pressure. We'll discuss colloids in detail later.
Crystalloids are solutes capable of crystallization that are easily mixed and dissolved in a solution. The
solutes may be electrolytes or nonelectrolytes, such as dextrose.
Crystalloid solutions contain small molecules that flow easily across semipermeable membranes, allowing
for transfer from the bloodstream into the cells and body tissues. This may increase fluid volume in both
the interstitial and intravascular spaces.

Crystalloid solutions are distinguished by their relative tonicity (before infusion) in relation to plasma.
Tonicity refers to the concentration of dissolved molecules held within the solution. 5,6 The following
sections discuss isotonic, hypotonic, and hypertonic crystalloid solutions in detail.
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ISOTONIC FLUIDS

Figure. How body flu...

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A solution is isotonic when the concentration of dissolved particles is similar to that of plasma. Isotonic
solutions have an osmolality of 250 to 375 mOsm/L. 7 With osmotic pressure constant both inside and
outside the cells, the fluid in each compartment remains within its compartment (no shift occurs) and cells
neither shrink nor swell. Because isotonic solutions have the same concentration of solutes as plasma,
infused isotonic solution doesn't move into cells. Rather, it remains within the extracellular fluid
compartment and is distributed between the intravascular and interstitial spaces, thus increasing
intravascular volume.6 Types of isotonic solutions include 0.9% sodium chloride (0.9% NaCl), lactated
Ringer's solution, 5% dextrose in water (D5W), and Ringer's solution.
A solution of 0.9% sodium chloride is simply salt water, and contains only water, sodium (154 mEq/L),
and chloride (154 mEq/L). It's often 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.
Because water goes where sodium goes, 0.9% sodium chloride increases fluid volume in extracellular
spaces. It's administered to treat low extracellular fluid, as in fluid volume deficit from hemorrhage, severe
vomiting or diarrhea, and heavy drainage from GI suction, fistulas, or wounds. Conditions commonly
treated with 0.9% sodium chloride include shock, mild hyponatremia, metabolic acidosis (such as diabetic
ketoacidosis), and hypercalcemia; patients requiring a fluid challenge may also benefit from 0.9% sodium
chloride solution. It's the fluid of choice for resuscitation efforts. 2,8 In addition, it's the only fluid used with
administration of blood products.
Remember that because 0.9% sodium chloride replaces extracellular fluid, it should be used cautiously in
certain patients, such as those with cardiac or renal disease, because of the potential for fluid volume
overload.
Lactated Ringer's (LR), also known as Ringer's lactate or Hartmann solution, 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. Because of this, LR is another choice for first-line fluid resuscitation for certain
patients, such as those with burn injuries. It contains 130 mEq/L of sodium, 4 mEq/L of potassium, 3
mEq/L of calcium, and 109 mEq/L of chloride. LR doesn't provide calories or magnesium, and has limited
potassium replacement.2
LR is used to replace GI tract fluid losses, fistula drainage, and fluid losses due to burns and trauma. It's
also given to patients experiencing acute blood loss or hypovolemia due to third-space fluid shifts. 6 Both
0.9% sodium chloride and LR may be used in many clinical situations, but patients requiring electrolyte
replacement (such as surgical or burn patients) will benefit more from an infusion of LR. 6

LR is metabolized in the liver, which converts the lactate to bicarbonate. As an alkalinizing solution, LR is
often administered to patients who have metabolic acidosis. Don't give LR to patients who can't
metabolize lactate for some reason, such as those with liver disease or those experiencing lactic acidosis.
Because a normal liver will convert it to bicarbonate, LR shouldn't be given to a patient whose pH is
greater than 7.5. Because it does contain some potassium, use caution in patients with renal failure. 3
Ringer's solution, like LR, contains sodium, potassium, calcium, and chloride in similar concentrations
(147 mEq/L of sodium, 4 mEq/L of potassium, 4 mEq/L of calcium, and 156 mEq/L of chloride). But it
doesn't contain lactate. Ringer's solution is used in a similar fashion as LR, but doesn't have the
contraindications related to lactate. However, because it's not an alkalizing agent, it may not be indicated
for patients with metabolic acidosis.3,6
D5W is unique in that it may be categorized as both an isotonic and a hypotonic solution. The amount of
dextrose in this solution makes its initial tonicity similar to that of intravascular fluid, making it an isotonic
solution. But dextrose (in this concentration) is rapidly metabolized by the body, leaving no osmotically
active particles in the plasma.6
D5W provides free water: free, unbound water molecules small enough to pass through membrane pores
to the intracellular and extracellular spaces. This smaller size allows the molecules to pass more freely
between compartments, thus expanding both compartments simultaneously.6 The free water initially
dilutes the osmolality of the extracellular fluid; once the cell has used the dextrose, the remaining saline
and electrolytes are dispersed as an isotonic electrolyte solution, providing additional hydration for the
extracellular fluid compartment. Dextrose solutions also provide free water for the kidneys, aiding renal
excretion of solutes. Because it provides free water following metabolism, D 5W is also considered a
hypotonic solution.6
D5W is basically a sugar water solution that provides 170 calories per liter, but it doesn't replace
electrolytes. However, it's appropriate to treat hypernatremia because it dilutes the extra sodium in
extracellular fluid.
D5W shouldn't be used in isolation to treat fluid volume deficit because it dilutes plasma electrolyte
concentrations. It's also contraindicated in these clinical circumstances:
* for resuscitation, because the solution won't remain in the intravascular space.
* in the early postoperative period, because the body's reaction to the surgical stress may cause an
increase in antidiuretic hormone secretion.2
* in patients with known or suspected increased intracranial pressure (ICP) due to its hypotonic properties
following metabolism.
Although it supplies some calories, D5W doesn't provide enough nutrition for prolonged use.
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Nursing considerations for isotonic solutions

Be aware that patients being treated for hypovolemia can quickly develop hypervolemia (fluid volume
overload) following rapid or overinfusion of isotonic fluids. Document baseline vital signs, edema status,

lung sounds, and heart sounds before beginning the infusion, and continue monitoring during and after
the infusion.
Frequently assess the patient's response to I.V. therapy, monitoring for signs and symptoms of
hypervolemia, such as hypertension, bounding pulse, pulmonary crackles, dyspnea/shortness of breath,
peripheral edema, jugular venous distention (JVD), and extra heart sounds, such as S 3. Monitor intake
and output, hematocrit, and hemoglobin. Elevate the head of bed at 35 to 45 degrees, unless
contraindicated. If edema is present, elevate the patient's legs. Note if the edema is pitting or nonpitting
and grade pitting edema. For an example, see Checking for pitting edema.
Also monitor for signs and symptoms of continued hypovolemia, including urine output of less than 0.5
mL/kg/hour, poor skin turgor, tachycardia, weak, thready pulse, and hypotension. 2
Educate patients and their families about signs and symptoms of volume overload and dehydration, and
instruct patients to notify their nurse if they have trouble breathing or notice any swelling. Instruct patients
and families to keep the head of the bed elevated (unless contraindicated).
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HYPOTONIC FLUIDS
Compared with intracellular fluid (as well as compared with isotonic solutions), hypotonic solutions have a
lower concentration, or tonicity, of solutes (electrolytes). Hypotonic I.V. solutions have an osmolality less
than 250 mOsm/L.6
Infusing a hypotonic solution into the vascular system causes an unequal solute concentration among the
fluid compartments. The infusion of hypotonic crystalloid solutions lowers the serum osmolality within the
vascular space, causing fluid to shift from the intravascular space to both the intracellular and interstitial
spaces. These solutions will hydrate cells, although their use may deplete fluid within the circulatory
system.6
Types of hypotonic fluids include 0.45% sodium chloride (0.45% NaCl), 0.33% sodium chloride, 0.2%
sodium chloride, and 2.5% dextrose in water. Hypotonic solutions assist with maintaining daily body fluid
requirements, but don't contain any electrolytes (except for sodium and chloride) or calories (except for
D5W, which is also considered a hypotonic solution after metabolism). 3 Administering hypotonic saline
solutions also helps the kidneys excrete excess fluids and electrolytes.
All these solutions provide free water, sodium, and chloride, and replace natural fluid losses. In addition,
the solution containing dextrose offers a low level of caloric intake.

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Nursing considerations for hypotonic solutions

Hypotonic fluids are used to treat patients with conditions causing intracellular dehydration, such as
diabetic ketoacidosis, and hyperosmolar hyperglycemic state, when fluid needs to be shifted into the cell.
Be aware of how the fluid shift will affect various body systems. The lower concentration of solute within
the vascular bed will shift the fluid into the cells and also into the interstitial spaces.
Use caution when infusing hypotonic solutions; the decrease in vascular bed volume can worsen existing
hypovolemia and hypotension and cause cardiovascular collapse. 6
Monitor patients for signs and symptoms of fluid volume deficit as fluid is "pulled back" into the cells and
out of the vascular bed. In older adult patients, confusion may also be an indicator of a fluid volume
deficit. Instruct patients to inform a nurse if they feel dizzy or just "don't feel right."
Never give hypotonic solutions to patients who are at risk for increased ICP because of a potential fluid
shift to the brain tissue, which can cause or exacerbate cerebral edema. In addition, don't use hypotonic
solutions in patients with liver disease, trauma, or burns due to the potential for depletion of intravascular
fluid volume.2
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HYPERTONIC SOLUTIONS
Compared with intracellular fluid (as well as with isotonic solutions), hypertonic solutions have a higher
tonicity or solute concentration, causing an unequal pressure gradient between the inside and outside of
the cells. Hypertonic fluids have an osmolarity of 375 mOsm/L or higher. The osmotic pressure gradient
draws water out of the intracellular space, increasing extracellular fluid volume. Because of this property,
hypertonic solutions are used as volume expanders. Hypertonic solutions may be prescribed for patients
with severe hyponatremia. Patients with cerebral edema may also benefit from an infusion of hypertonic
sodium chloride.6
Hypertonic sodium chloride solutions contain a higher concentration of sodium and chloride than that
normally contained in plasma. Examples include 3% sodium chloride (3% NaCl), with 513 mEq/L of
sodium and chloride, and 5% sodium chloride (5% NaCl), with 855 mEq/L of sodium and chloride. As the
infusion of these hypertonic solutions raise the sodium level in the bloodstream, osmosis comes into play,
removing fluid from the intracellular space, and shifting it into the intravascular and interstitial spaces.
These solutions are highly hypertonic and should be used only in critical situations to treat hyponatremia.
Give them slowly and cautiously to avoid intravascular fluid volume overload and pulmonary edema. 3
When dextrose is added to isotonic or hypotonic solutions, the net result can be a slightly hypertonic
solution due to the higher solute concentration. Thus, adding D 5W to sodium chloride solutions (such as
5% dextrose and 0.45% sodium chloride, and 5% dextrose and 0.9% sodium chloride) or to lactated
Ringer's solutions such as D5LR will provide the same electrolytes already discussed for each of those
solutions, with the addition of calories. Plain glucose solutions with a concentration higher than 5%, such
as 10% dextrose in water (D10W), are also considered hypertonic. D10W provides free water and calories
(340 per liter), but not electrolytes.
Twenty percent dextrose in water (D20W) is an osmotic diuretic, meaning the fluid shift it causes between
various compartments promotes diuresis.

Fifty percent dextrose in water (D50W) is a highly concentrated sugar solution. It's administered rapidly via
I.V. bolus to treat patients with severe hypoglycemia. 3
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Nursing considerations for hypertonic solutions

Maintain vigilance when administering hypertonic saline solutions because of their potential for causing
intravascular fluid volume overload and pulmonary edema. 2 Hypertonic sodium chloride solutions should
be administered only in high acuity areas with constant nursing surveillance for potential complications.
Hypertonic sodium chloride shouldn't be given for an indefinite period of time. Prescriptions for their use
should state the specific hypertonic fluid to be infused, the total volume to be infused and infusion rate, or
the length of time to continue the infusion. As an additional precaution, many institutions store hypertonic
sodium chloride solutions apart from regular floor stock I.V. fluids, so they must be ordered separately
from the pharmacy.
Monitor serum electrolytes and assess for signs and symptoms of hypervolemia. Because hypertonic
solutions can cause irritation, damage, and thrombosis of the blood vessel, some of these solutions
shouldn't be administered peripherally. The Infusion Nurses Society states that "[p]arenteral nutrition
solutions containing final concentrations exceeding 10% dextrose should be administered through a
central vascular access device with the tip located in the central vasculature, preferably the
subclavian/right atrium junction for adults."9
Instruct patients to notify a nurse if they develop breathing difficulties or if they feel their heart is beating
very fast.
Hypertonic solutions shouldn't be given to patients with cardiac or renal conditions who are dehydrated.
These solutions affect renal filtration mechanisms and can cause hypervolemia. Patients with conditions
causing cellular dehydration, such as diabetic ketoacidosis shouldn't be given hypertonic solutions,
because it will exacerbate the condition.
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Why colloid solutions stay put

Unlike crystalloids, colloids contain molecules too large to pass through semipermeable membranes,
such as capillary walls. Because they remain in the intravascular compartment, they're also known as
volume expanders or plasma expanders. Examples include albumin, dextrans, and hydroxyethylstarches.
Colloids expand intravascular volume by drawing fluid from the interstitial spaces into the intravascular
compartment through their higher oncotic pressure. They have the same effect as hypertonic crystalloids
of increasing intravascular volume, but require administration of less total volume compared with
crystalloids. In addition, colloids have a longer duration of action than crystalloids because the molecules
remain within the intravascular space longer. The effects of colloids can last for several days if capillary
wall linings are intact and working properly. Colloids are indicated for patients exhibiting hypoproteinemia,
and malnourished states, as well as for those who require plasma volume expansion but who can't
tolerate large infusions of fluid. Patients undergoing orthopedic surgery or reconstructive procedures with
an elevated potential for thrombus formation may also benefit from colloid solutions. 6

Five percent albumin (Human albumin solution) is one of the most commonly utilized colloid solutions. It
contains plasma protein fractions obtained from human plasma and works to rapidly expand the plasma
volume. It's used for volume expansion, moderate protein replacement, and achievement of
hemodynamic stability in shock states. Albumin is also available in a 25% solution, which is much more
hypertonic and can draw about four times its volume from the interstitial fluid into the vascular
compartment within 15 minutes of administration.
Albumin is considered a blood transfusion product and requires all the same nursing precautions used
when administering other blood products. It can be expensive and its availability is limited to the supply of
human donors.9
Albumin is, however, contraindicated in patients with the following conditions: severe anemia, heart
failure, or a known sensitivity to albumin. In addition, angiotensin-converting enzyme inhibitors should be
withheld for at least 24 hours before administering albumin because of the risk of atypical reactions, such
as flushing and hypotension.7
A study was conducted during 20012003 called the Saline versus Albumin Fluid Evaluation (SAFE)
study. This study compared the use of albumin and saline for ICU patients requiring fluid resuscitation.
Among 6997 patients studied, 3497 received 4% albumin solution and 3500 received 0.9% sodium
chloride solution. The aim of the study was to determine if one fluid was better than the other for
preventing death. After 28 days, researchers found similar outcomes in both groups. 10 Because neither
solution has proven clearly superior, healthcare providers use their judgment to decide which fluid to
administer to critically ill patients in the ICU.
Besides albumin, several synthetic colloid preparations are available for patient use. Low-molecular
weight dextran (LMWD) and high-molecular weight dextran (HMWD) are synthetic plasma expanders
infused to draw water into the intravascular space.
* LMWD contains polysaccharide molecules that behave like colloids with an average molecular weight of
40,000 (dextran 40). It contains no electrolytes and is used for volume expansion and support. LMWD is
used for early fluid replacement and to treat shock related to vascular volume loss, such as that produced
by burns, hemorrhage, surgery, or trauma. It's used to prevent venous thromboembolism during surgical
procedures, because its mechanism of action is to prevent the sludging of blood. LMWD is
contraindicated in patients with thrombocytopenia, hypofibrinogenemia, and hypersensitivity to dextran. 7
* HMWD contains polysaccharide molecules with an average molecular weight of 70,000 (available as
dextran 70) or 75,000 (available as dextran 75). It also contains no electrolytes. HMWD shouldn't be
given to patients in hemorrhagic shock.
Dextran solutions are available in either saline or glucose solutions. Dextran interferes with lab blood
crossmatching, so if a type and cross is anticipated, draw the patient's blood before administering
dextran. Dextran may interfere with some other blood tests and may also cause anaphylactoid reactions. 7
Hydroxyethalstarches, such as hetastarch (6%) and hespan, are another form of hypertonic synthetic
colloids used for volume expansion. They contain 154 mEq/L of sodium and chloride and are used for
hemodynamic volume replacement following major surgery and to treat major burns. Synthetic colloid
preparations are less expensive than albumin and their effects can last 24 to 36 hours. 9
Unlike other colloids, hetastarch doesn't interfere with blood typing or crossmatching. Hetastarch is
contraindicated in patients with liver disease and severe cardiac and renal disorders. It may also cause a
severe anaphylactoid reaction.6

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Nursing considerations for colloids

Because colloids pull fluids from the interstitial space to the vascular space, the patient is at risk for
developing fluid volume overload. If the patient's fluid imbalance doesn't respond to either crystalloids or
colloids, blood transfusions or other treatment may be necessary.2
As for blood products, use an 18-gauge or larger needle to infuse colloids. Monitor the patient for signs
and symptoms of hypervolemia, including increased BP, dyspnea, crackles in the lungs, JVD, edema, and
bounding pulse. Closely monitor intake and output. Colloid solutions can interfere with platelet function
and increase bleeding times, so monitor the patient's coagulation indexes. 9 Elevate the head of bed
unless contraindicated.
Anaphylactoid reactions are a rare but potentially lethal adverse reaction to colloids. Take a careful allergy
history from patients receiving colloids (or any other drug or fluid), asking specifically if they've ever had a
reaction to an I.V. infusion.
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Use best practices for optimal outcomes

No matter what I.V. fluid you're administering, follow best practices to ensure optimal response to therapy
and prevent complications. For example, assess and document baseline vital signs, heart and lung
sounds, and fluid volume status.
As with any drug, make sure you're familiar with the type of fluid being administered, the rate and duration
of the infusion, the fluid's effects on the body, and potential adverse reactions. Throughout therapy,
monitor the patient's response to treatment, watching closely for any signs and symptoms of
hypervolemia or hypovolemia. Monitor lab values to assess kidney function and fluid status. Regularly
check the venous access site for signs of infiltration, inflammation, infection, or thrombosis.
Educate the patient and the family about the prescribed therapy, including potential complications and
symptoms that require immediate attention.