LEARNING OUTCOME 1
Discuss the function, distribution, composition, movement, and regulation of
fluids and electrolytes in the body.
Concepts for Lecture
1. A delicate balance of fluids, electrolytes, and acids and bases is
2. Water is vital to health and normal cellular function. It serves as a
medium for metabolic reactions within the cells; a transporter for
nutrients, waste products, and other substances; a lubricant; an insu-
3. Fluids and electrolytes move among the body compartments by
osmosis, diffusion, filtration, and active transport. The volume and
4. Normally, fluid intake balances fluid loss. The thirst mechanism is
the primary regulator of fluid intake. There are four routes of fluid
loss: urine, insensible loss through the skin as perspiration and
through the lungs as water vapor in the expired air, noticeable loss
C
HAPTER
52
FLUID, ELECTROLYTE,
AND ACID–BASE BALANCE
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UGGESTIONS FOR
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LASSROOM
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CTIVITIES
• Using the example of a tea bag and a glass of hot
water, have the students explain diffusion, osmo-
sis, and filtration and how these relate to the
movement of body fluids and electrolytes.
•
Divide the students into groups. Assign each
group an electrolyte. Have the students
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UGGESTIONS FOR
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CHAPTER 52 / Fluid, Electrolyte, and Acid–Base Balance 399
LEARNING OUTCOME 2
Describe the regulation of acid–base balance in the body, including the roles
of buffers, the lungs, and the kidneys.
Concepts for Lecture
1. An important part of regulating the chemical balance or homeostasis
of body fluids is regulating their acidity or alkalinity, which is meas–
ured as pH. The pH reflects the hydrogen concentration of the solu–
2. Buffers prevent excessive changes in the pH by removing or releas-
ing hydrogen ions. The major buffer system in ECF is the bicar-
3. The lungs help regulate acid–base balance by eliminating or retain-
ing carbon dioxide, a potential acid. Combined with water, carbon
dioxide forms carbonic acid. This chemical reaction is reversible.
4.
The kidneys are the ultimate long-term regulator of acid–base balance.
They are slower to respond to changes, requiring hours to days to correct
imbalances, but their response is more permanent and selective than that
of the other systems. Kidneys maintain acid–base balance by selectively
excreting or conserving bicarbonate and hydrogen ions. When excess
S
UGGESTIONS FOR
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LASSROOM
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CTIVITIES
• Invite a critical care clinical specialist to review
acid–base balance and the importance of as-
sessing and interpreting these values in the set-
ting where the nurse practices.
•
Invite a faculty member of the chemistry de-
partment to present a visual demonstration of
buffers, acids, and bases, relating this infor-
mation to the biochemistry of the human
body.
400 CHAPTER 52 / Fluid, Electrolyte, and Acid–Base Balance
LEARNING OUTCOME 3
Identify factors affecting normal body fluid, electrolyte, and acid–base
balance.
Concepts for Lecture
1. Factors affecting normal body fluid, electrolyte, and acid–base bal-
ance include age, gender and body size, environmental temperature,
and lifestyle.
atrial nutriuretic hormone may contribute to impaired ability to con-
serve water in older people.
Gender and body size—fat cells contain little water, and lean tis-
sue has an increased water content. People with a greater percentage
of body fat have less body fluid. Women have proportionally greater
body fat than men and have less body water than men.
LEARNING OUTCOME 4
Discuss the risk factors for, and the causes and effects of fluid, electrolyte,
and acid–base imbalances.
Concepts for Lecture
1. Common risk factors for fluid, electrolyte, and acid–base imbalances
are listed in Box 52–3 and include chronic diseases (e.g., lung dis-
2.
Fluid imbalances are of two basic types: isotonic and osmolar. Isotonic
imbalances occur when water and electrolytes are lost or gained in equal
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UGGESTIONS FOR
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LASSROOM
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CTIVITIES
•
Provide examples of the factors affecting
normal body fluid, electrolyte, and acid–base
balance and have the students identify the ef-
fect each may have.
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UGGESTIONS FOR
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LINICAL
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CTIVITIES
• Ask the students to review the charts and care
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UGGESTIONS FOR
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LASSROOM
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CTIVITIES
• Divide the students into groups. Assign each
group a fluid or acid–base imbalance. Ask the
students to develop a teaching sheet for clients
and families describing the problem, causes,
signs and symptoms, and treatment in a way that
clients will understand.
•
Divide the students into groups. Assign each
group an electrolyte. Have the students devel-
op a pamphlet about the function of the elec-
discuss fluid and electrolyte problems commonly
seen in clients needing dialysis and how these are
demonstrated in the clients.
• Review intake and output records of various
factors, clinical manifestations, and nursing interventions for isoton-
ic fluid volume excess. The risk for dehydration increases with older
age due to decreased thirst sensation. Also at risk for dehydration are
clients who are hyperventilating or have prolonged fever or are in
diabetic ketoacidosis and those receiving enteral feedings with insuf-
3. Table 52–6 lists electrolyte imbalances (hypo– and hypernatremia,
4.
Table 52–7 lists acid–base imbalances (respiratory acidosis and alkalo-
LEARNING OUTCOME 5
Collect assessment data related to the client’s fluid, electrolyte, and acid–base
balance.
Concepts for Lecture
1. Components of the assessment include the nursing history, physical
assessment of the client, clinical measurement, and review of labora-
balance. The Assessment Interview in the text provides examples of
questions to elicit information regarding fluid, electrolyte, and acid–
base balance.
Table 52–8 lists the focused physical assessment of fluid, elec-
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UGGESTIONS FOR
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CTIVITIES
• Invite respiratory or critical care nurses to dis-
cuss interpretation of blood gases and assessment
criteria related to them.
•
Have the students use the Assessment Inter-
view to practice obtaining information about
fluid, electrolyte, and acid–base balance on
each other.
•
Have the students practice the focused physi-
cal assessment in Table 52–8 in the textbook
balance using either the tools presented in the
text or the assessment form used by the clinical
agency. Discuss findings as they are related to
the client’s medical diagnosis.
• Have the students perform specific gravity
measurements using the equipment provided
402 CHAPTER 52 / Fluid, Electrolyte, and Acid–Base Balance
(sodium, potassium, chloride, calcium, magnesium, phosphate, and se-
rum osmolality). Box 52–6 lists normal values of arterial blood gases
LEARNING OUTCOME 6
Identify examples of nursing diagnoses, outcomes, and interventions for
clients with altered fluid, electrolyte, or acid–base balance.
Concepts for Lecture
1. NANDA diagnostic labels that relate to fluid and acid–base imbal-
ances include Deficient Fluid Volume, Excess Fluid Volume, Risk for
2. Fluid, electrolyte, and acid–base imbalances affect many other body
3. When planning care, the nurse identifies nursing interventions that
will assist the client to achieve the following broad goals: maintain
or restore normal fluid balance, maintain or restore normal balance
of electrolytes in the intracellular and extracellular compartments,
maintain or restore pulmonary ventilation and oxygenation, and pre-
vent associated risks (tissue breakdown, decreased cardiac output,
LEARNING OUTCOME 7
Teach clients measures to maintain fluid and electrolyte balance.
Concepts for Lecture
1. Client Teaching: Wellness Care and Promoting Fluid and Electrolyte
Balance in the text includes measures to teach clients, such as: con-
S
UGGESTIONS FOR
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LASSROOM
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CTIVITIES
• Discuss NANDA diagnoses related to fluid bal-
ance, emphasizing the definition, defining char-
acteristics, etiology, or risk factors.
•
Provide the students with a case study of a
client who has a fluid volume problem. Ask
the students to develop a care plan for this
client.
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UGGESTIONS FOR
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LASSROOM
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CTIVITIES
•
Have the students review the Client Teaching
and Practice Guidelines features in the text-
book. Ask them to suggest additions to these
guidelines.
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UGGESTIONS FOR
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2. Client Teaching: Home Care and Fluid, Electrolyte, and Acid–Base
Balance in the text includes additional teaching topics. Topics in-
3. Practice Guidelines: Facilitating Fluid Intake in the text includes
reasons for required intake and amount needed and the following
4.
Practice Guidelines: Helping Clients Restrict Fluid Intake in the text
includes reasons for and the amount of the restriction and the following
LEARNING OUTCOME 8
Implement measures to correct imbalances of fluids and electrolytes or acids
and bases such as enteral or parenteral replacements and blood transfusions.
Concepts for Lecture
1. Fluids and electrolytes can be provided orally if the client is not
vomiting, has not experienced an excessive fluid loss, and has an in-
2. Some clients can benefit from oral supplements of electrolytes, par-
ticularly when a medication is prescribed that affects electrolyte bal-
ance, when dietary intake is inadequate for a specific electrolyte, or
an order to do so, and to consult with a primary care provider before
using a salt substitute, as many contain potassium. People who in-
gest insufficient milk and milk products or those on long-term corti-
S
UGGESTIONS FOR
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LASSROOM
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CTIVITIES
• Invite nurses who serve on an IV team to discuss
assessment criteria related to clients receiving in-
travenous therapy, including nursing interven-
tions for infiltrated intravenous lines.
•
Make a poster with various intravenous cathe-
ters, including central lines, and types of fluids
and dressing materials for the students to re-
view.
•
Show videotaped demonstrations for starting,
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UGGESTIONS FOR
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CTIVITIES
frames for container, tubing, needle (catheter),
and dressing changes. Compare to protocols
for TPN.
• Demonstrate the use of the intravenous pumps
3.
Parenteral fluid and electrolyte replacement interventions are described
in Skill 52–1: Starting an Intravenous Infusion; Skill 52–2: Monitoring
an Intravenous Infusion; Skill 52–3: Changing an Intravenous Container,
Tubing, and Dressing; Skill 52–4: Discontinuing an Intravenous Infu-
LEARNING OUTCOME 9
Evaluate the effect of nursing and collaborative interventions on the client’s
fluid, electrolyte, or acid–base balance.
Concepts for Lecture
1. The nurse collects data to evaluate the effectiveness of goals, desired
outcomes, and nursing and collaborative interventions as identified
LEARNING OUTCOME 10
Verbalize the steps used in:
a. Starting an intravenous infusion.
b. Monitoring an intravenous infusion.
c. Changing an intravenous container and tubing.
S
KILL
52–1:
S
TARTING AN INTRAVENOUS INFUSION
C
OMPETENCY
D
EMONSTRATED
?
Yes
No
2. Explained the procedure to the client and discussed the pur-
pose of the therapy.
procedures.
4. Performed hand hygiene and observed other infection control
S
UGGESTIONS FOR
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LASSROOM
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CTIVITIES
•
Have the students review the nursing diagno-
sis reference book used by the agency for sug-
gested goals/outcomes/interventions for
NANDA diagnoses related to fluid, electro-
lyte, and acid–base balance. Have the students
identify evaluation data required to determine
the effectiveness of each of these.
6. Assisted the client to a position of comfort.
8. Set up equipment on a towel or disposable pad.
9. Applied clean gloves. .
10. Opened the IV start kit and inspected its contents, especially
the tip of the IV catheter.
11. Applied a tourniquet 3″ to 4″ above the venipuncture site to
obstruct venous blood flow.
presses over the intended vein for 10 to 15 minutes.
12. Instructed the patient to hold his or her arm lower than the
heart and to open and close the fist. Palpated for a vein. If the
site could not be felt:
catheter and activated the safety mechanism. Flushed the
13.
Entered the skin gently, holding the catheter by the hub in
the dominant hand, bevel side up, at a 10° to 15° angle.
Inserted the catheter from directly over the vein. Ad-
14. Secured the catheter at the hub using either a commercial
securing device or tape as instructed by policy.
15. Removed gloves and performed hand hygiene.
16. Correctly documented the procedure.
S
KILL
52–2:
M
ONITORING AN INTRAVENOUS INFUSION
C
OMPETENCY
D
EMONSTRATED
?
Yes
No
1. Introduced self and verified client’s identity.
2. Explained the procedure to the client and discussed the
3. Identified compatibility considerations in preparing and
administering IV fluids and medication.
4. Performed hand hygiene and observed other infection
5. Identified the rationale for difference in rate of infusion
for IV solutions containing medications.
6. Applied the nine cardinal rules of safety in preparing and
administering IV drugs:
a.
Five rights.
7. Correctly calculated the flow rate after verifying health
9. Correctly documented the procedure. .
S
KILL
52–3:
C
HANGING AN INTRAVENOUS CONTAINER AND
TUBING
C
OMPETENCY
D
EMONSTRATED
?
Yes
No
1. Introduced self and verified client’s identity.
2. Explained the procedure to the client and discussed the
purpose of the therapy.
3. Gathered the appropriate equipment.
4. Performed hand hygiene and applied clean gloves.
5. Verified order, verified client identification, and checked
solution expiration date.
5. Inspected solution for clarity and leaks.
6. Attached label to solution if required by the agency.
tubing.
7. Removed IV tubing from the package and closed the roll-
er clamp and attached the extension tubing. If a 3-way
8. Removed the plastic protector from the IV bag and un-
covered the tubing spike. .
9. Inserted spike, inverted solution, and suspended solution
on IV pole.
10. Filled the drop chamber to ½ full.
11. Opened the roller clamp slowly while keeping the IV tubing
12.
Closed the roller clamp.
15. Adjusted the drip rate as ordered.
16. Dated the IV tubing.
17. Removed gloves and performed hand hygiene.
18. Correctly documented the procedure.
S
KILL
52–4:
D
ISCONTINUING AN INTRAVENOUS INFUSION
C
OMPETENCY
D
EMONSTRATED
?
Yes
No
1. Introduced self and verified client’s identity.
2. Explained the procedure to the client and discussed the
purpose of the procedure.
3. Gathered the appropriate equipment.
4. Performed hand hygiene and observed other infection
control procedures.
5. Verified client identification.
6. Verified the order to discontinue IV therapy.
7. Moved the roller clamp on the IV tubing to the closed
position.
8. Applied clean gloves.
CHAPTER 52 / Fluid, Electrolyte, and Acid–Base Balance 407
avoid injury to the vein. .
9. While stabilizing the IV catheter at all times, pulled the
10. While slowing removing the IV catheter, applied firm but
gentle pressure over the insertion site with 2×2 or 4×4 gauze.
11. Inspected the tip of the catheter to ensure patency.
12. Inspected the site for signs of infection (erythema, edema,
discharge).
13.
Applied a dressing over insertion site, ensuring that the
dressing was not too tight.
14. Properly disposed of used catheter per agency protocol.
15. Removed gloves and performed hand hygiene.
16. Correctly documented the procedure.
S
KILL
52–5:
C
HANGING AN INTRAVENOUS CATHETER TO AN
INTERMITTENT INFUSION LOCK
C
OMPETENCY
D
EMONSTRATED
?
Yes
No
1. Introduced self and verified the client’s identity.
2. Explained the procedure to the client and discussed the
purpose of the therapy.
3. Gathered the appropriate equipment.
4. Performed hand hygiene and observed other infection
control procedures.
5. Applied clean gloves.
6. Verified client identification.
7. Verified the health care provider’s order.
8. Filled the IV lock with saline.
9. Removed the IV dressing as needed to access the IV hub.
10. Loosened the IV tubing from the IV catheter and removed
the IV tubing.
11. Attached the IV lock to the IV catheter, maintaining asepsis.
12. Cleansed the port of the IV lock with alcohol.
13.
saline slowly, assessing the IV catheter site.
14. Withdrew the saline syringe.
15. Applied or reinforced the dressing as needed.
16. Removed gloves and performed hand hygiene.
16. Correctly documented the procedure.
Concepts for Lecture
1. Although the primary care provider is responsible for ordering IV
therapy for clients, nurses initiate, monitor, and maintain the pre-
2. Before starting an infusion, the nurse determines the following:
The type and amount of solution to be infused
3. If solutions are prepared by the pharmacy or another department, the
nurse must verify that the solution supplied exactly matches that
408 CHAPTER 52 / Fluid, Electrolyte, and Acid–Base Balance
LEARNING OUTCOME 11
Recognize when it is appropriate to delegate aspects of fluid, electrolyte,
and acid–base balance to unlicensed assistive personnel.
Concepts for Lecture
1. Due to the need for knowledge of anatomy and use of sterile tech-
2. UAP may care for clients receiving IV therapy, and the nurse must
ensure that the UAP knows how to perform routine tasks such as
LEARNING OUTCOME 12
Demonstrate appropriate documentation and reporting of fluid, electro-
lyte, and acid–base balance activities.
Concepts for Lecture
1. Include the date and time of the venipuncture; type, length, and
gauge of the needle or catheter; venipuncture site, how many at-