Maintaining fluid

balance
Barbara Workman
Homeostasis is the term used to describe the balance that the body maintains between fluid intake and fluid output. It
is estimated that a healthy person requires at least 2–2.5 litres, intake of fluid daily (Edwards 2001) which, together
with food and metabolic processes, results in an intake of approximately 3 litres of fluid daily. Patients will vary as to
how much and how often they like to drink, and some will need more encouragement than others to maintain or
increase a satisfactory fluid intake.
Fluid intake can be by oral drinks ,food, tube feeds and intravenous fluids.
Fluid output may occur via urine, vomiting, feces and diarrhea, sweat, gastric secretions, or
wound drainage.

The lack of adequate fluid intake can lead to dehydration which presents (Morrison 2000) as:
● dry mouth and lips
● dry skin with loss of elasticity (turgor)
● weakness and lethargy
● thirst
● sunken eyes
● small concentrated urine output (oliguria)
● confusion
● tachycardia
● poor peripheral perfusion leading to pallor.( CRT / capillary refill time ) more than 3 seconds

Accurate measurement of a patient’s fluid intake and output will identify those patients at risk of becoming
dehydrated or over hydrated.
Particularly vulnerable patients are:
● the elderly, who may have lost their thirst stimulus and neglect to drink
● the confused or neurologically disordered, who may fail to respond to thirst
● those whose conditions are deteriorating, e.g. with renal or cardiac failure
● post-operative patients
● emergency admissions as their fluid needs may be initially underestimated
● those who are nil by mouth.

Patients’ fluid requirements will increase:

● in hot weather
● with a pyrexia (high temperature)
● if a urinary catheter is in situ
● if constipated
● if there is fluid loss from the gastro-intestinal tract, such as diarrhea,
vomiting, or nasogastric or wound drainage.

Fluid overload / edema / over hydration

It is possible to over hydrate a patient, particularly when administering
intravenous fluids. The patient may present with the following symptoms
(Perry and Potter 1997; Edwards 2000):
● feeble, weak, irregular pulse
● breathlessness and cough, expectorating white or pink frothy sputum
● discomfort and restlessness
● edema, particularly around ankles and sacrum
● lethargy
● anxiety
● distended neck veins
● raised / increase blood pressure
● raised fluid intake and insufficient output on fluid balance chart.

Careful monitoring of a patient’s fluid intake should detect these signs and symptoms early so that the fluid intake can
be reduced and the fluid overload reversed. Report your observations to senior staff and medical practitioner
immediately.

Peripheral intravenous therapy

Intravenous therapy (IVT) / IV line is a very common clinical intervention in modern acute care, and at least 50 per
cent of patients admitted in the UK may have intravenous interventions during their stay (Wilkinson1996).

Patients receiving IVT are either unable to take fluids and medications orally to meet their needs, or these substances
are not suitable to be given by the oral route. IVT by the peripheral route is an invasive procedure and all IVT care
should follow aseptic principles to prevent infection. The patient’s comfort and safety are of central importance during
the infusion.

Spencer (1996) identifies some uses of IVT as:

● fluid and electrolyte replacement
● blood transfusion therapy
● drug administration, ready access in emergency
● parenteral nutrition.

Fluids commonly used in intravenous therapy include the following.

0.9% sodium chloride in water ( N/S 0,9 % )

This is isotonic and therefore does not encourage fluid to move from the intracellular compartments (cells) to the
extracellular compartments (plasma and interstitial fluid), but replaces fluid lost from the circulation such as that lost
by hemorrhage or dehydration.

Sodium chloride can be infused in other strengths to correct electrolyte imbalance, e.g. 1.8% or 3%. These
concentrations are hypertonic and so draw fluid from the cells into the plasma and interstitial
fluid compartments, thus increasing the fluid in circulation.

Hypotonic sodium chloride 0.45%

This can be used to correct severe dehydration arising from conditions such as diabetic ketoacidosis, and returns fluid
to the cells. Too much sodium chloride by infusion can result in fluid and sodium overload, and potassium imbalance
(Hand 2001), and therefore should be monitored
closely.

5% dextrose in water
This isotonic fluid provides fluid replacement without disturbing the electrolyte balance and provides energy up to
170 calories in 1 litre(Hand 2001). Stronger concentrations of dextrose such as 10% or 20% may be used to provide
calorie intake for patients who are temporarily unable to eat. Dextrose infusions, especially when containing
potassium, are acidic and may irritate a patient’s veins causing phlebitis after several days, use.

Other substances may be used to expand intravascular volume, such as:

● blood and its derivatives
● artificial colloids such as dextrans, hydroxyethyl starch (HES) and gelatin derivatives. These are used to expand the
plasma volume when there have been large blood losses.

Intervention:
commencing intravenous therapy / intravenous line insertion

Equipment :
● Cannula –IV catheter : Use the smallest size as possible, depending on the patient’s treatment
needs, to reduce trauma to the vein (RCN 1999).
● Antiseptic skin preparation, e.g. 2% chlorhexidine solution or
70% alcohol wipes (Ayliffe et al. 1999).
● Sterile tape and sterile dressing or designated IV dressing.
● Sterile gloves (correct size for the trained nurse or doctor inserting the cannula).
● Towel or disposable waterproof pad to protect the bed.
● Tourniquet.
● Intravenous infusion administration set.
● IV fluid as prescribed.
● Prescription sheet.
● 10 ml 0.9% saline solution to flush cannula; needle and 10 ml
syringe to administer.
● Disinfectant hand rub.
● IV pole / IV Stand – this may be portable with casters, or fixed to the bed.
● Receiver./ kidney basin
. bandage scissors

Procedure

Summary of IV complications
Local complications

Infiltration
Also known as tissuing. Fluid no longer enters the vein, because either the cannula has slipped out of the vein or the
vein has collapsed, causing a blockage and backflow of fluid into the interstitial spaces (Hecker 1988).
Signs/symptoms: Swelling, cool blanched skin, leakage from cannula, infusion slow or stopped, loose cannula.
Interventions: Discontinue IV, elevate arm on pillows or a sling, monitor limb for circulation, motor and sensation.
Advise patient that the swelling will recede slowly.

Extravasation
This is when vesicant (toxic) drugs, e.g. 10% or 20% dextrose, or cytotoxic drugs have infiltrated the tissues rather
than isotonic fluid, and cause tissue damage (Lamb 1996).
Signs/symptoms: As above, but swelling may be rapid and related to an IV drug injection. There may be some
discolouration of the skin.

TIP!
Interventions: As above, but follow local protocol to provide antidote or hydrocortisone injection. Extravasation can
result in tissue necrosis if not corrected quickly.

Phlebitis
The inner lining of the vein is irritated by:
● a chemical such as a drug, or acidic infusion such as potassium chloride
● a physical irritation from the type of cannula used
● the poor placement of a cannula
● mechanical irritation from poor fixation. Once inflamed the vein may then become infected.

Signs/symptoms: Swelling, inflammation, red, tense and hard vein (induration), possibly purulent discharge at cannula
exit site.
Interventions: Discontinue IV, send the cannula for Microscopy Culture and Sensitivity. Use smallest possible cannula
to reduce local irritation. Prevention includes careful aseptic site preparation and sterile dressing. Change cannula,
dressing and administration set every 48–72 hours. Monitor temperature and pulse every 4 hours for early detection.

Thrombophlebitis
This is when a thrombus (blood clot) forms inside the inflamed vein.
Signs/symptoms: Severe discomfort, inflammation visibly tracking up vein, pyrexia, tachycardia, enlarged lymph
glands, raised white cell count.
Interventions: As above, discontinue IV. May need resiting for IV antibiotics. Assess wound for appropriate dressing.

Nerve injury
This may result from the swelling caused by infiltration or extravasation, poor location of cannula, too many attempts
at cannulation, or bandaging or splinting too tightly or in an abnormal position (Masoorli 1995; Dougherty 1996).
Signs/symptoms: Pain in hand or arm before and after discontinuation of IV, numbness, tingling.
Interventions: Early detection of infiltration/extravasation and appropriate treatment. If patient complains of pain or
discomfort in hand during infusion, report it to a senior member of staff and
document it. Check for swelling or inflammation. Discontinue IV. If IVT is continued it should be recommenced on
the other limb.

Systemic complications

Bacteraemia
Micro-organisms in the blood. May go undetected until septicaemia develops. Septicaemia
Presence of pathogenic bacterial toxins in the blood.

Signs/symptoms: General malaise, pyrexia, rigors, nausea, vomiting and hypotension (Lamb 1996). May have evidence
of inflammation at cannula site and along the vein, but may be no visible inflammation.

Interventions: Notify the doctor. Take vital signs. Prevention requires maintenance of scrupulous aseptic technique
whenever manipulating the IV equipment. Always wash hands before and
after touching the system. Keep the number of extensions and three-way taps to the minimum. Change whole system
every 48–72 hours. Monitor cannula site for signs of infection. Blood cultures taken and the cannula tip should be sent
for microscopy, sensitivity and culture. IV antibiotics and additional therapeutic interventions will be required.

Emboli
Air, particle, catheter or thrombus; occurs when a foreign body enters the circulation and travels until it occludes a
small vessel:
● Air embolism may result from poor connections or air bubbles in the IV system.
● Particulate embolism may result from poorly dissolved drug components, or contamination of fluid.
● A catheter emboli may occur either during cannulation if the needle is inadvertently reinserted through the cannula,
severing it, or if scissors are used to remove tape, and cut the cannula by
accident.
● A thrombus may form inside a vein or on the end of a cannula, and be dislodged when the cannula is flushed.
Signs/symptoms: Breathlessness, chest pain, weak pulse, loss of consciousness. Air noted in administration set. If the
cannula is severed the end may be visible.
Interventions: Stop IV. Call for assistance. Take vital signs. Turn patient onto left-hand side to encourage air to rise
into the right atrium. If cannula end is visible attempt to retrieve it.

Circulatory overload

This can occur when too much fluid has been infused and the patient is not able to disperse it naturally. It may happen
due to a fault in an IV pump or administration set, or positional cannula, or due to over transfusion.
Signs/symptoms: Discomfort, neck vein enlargement, respiratory distress, cough with white or pink frothy sputum.
Interventions: Stop IV. Inform the doctor. Sit patient up and administer oxygen if prescribed. Ensure patients at risk
(see ‘Fluid have fluids administered by pump and check flow rate regularly. Diuretics may be given to
increase the rate of fluid excretion.

Drug incompatibility
Patients who are receiving IV drugs may be prescribed drugs that are incompatible with each other, which if
administered through the same or connecting IV administration sets may result in a chemical reaction causing
particles to form in the infusion.
Signs/symptoms: Blocked cannula, poor infusion flow, evidence of particles in infusion fluid, patient discomfort.
Interventions: Stop infusion, change administration set. Prevent by checking drug compatibility before administration.
Inform medical staff.

Speedshock
Caused by the rapid infusion of an IV drug resulting in a toxic blood concentration.
Signs/symptoms: Flushed face, headache, dizziness, chest tightness, tachycardia/ rapid pulse and hypotension.
Interventions: Stop infusion. Provide symptomatic relief, e.g. sitting up, oxygen therapy. Take vital signs. May need to
be given an antidote. Inform medical staff. Prevent by administering through a pump, burette or by
syringe driver.

Anaphylactic/allergic reaction
This is a result of allergen or drug reaction and can be very sudden and life-threatening.

Signs/symptoms: Itching, rash, watering eyes, sneezing, bronchospasm, facial flushing, and swelling, anxiety, rapid
swelling at IV site, sudden collapse, cardiac arrest.

Interventions: Discontinue infusion immediately. Call for urgent assistance. Take vital signs. Maintain airway.
Administer epinephrine according to local policy. Prevent by taking a thorough history of allergy, and
monitor patient closely when giving potential allergens.

Removal of cannulas
Cannulas should be removed as soon as possible after therapy has been
discontinued (Spencer 1996), otherwise patients could be exposed to
unnecessary infection risks.
Questions :

1. What do you call the condition if the body fluid more than body requirement ?
a. Over hydration c. rehydration
b. Dehydration d. normal hydration

2. the balance that the body maintains between fluid intake and fluid output is called :
a. homeostasis c. encouragement
b. approximately d. normal balance

3. Fluid output may occur via :

a. Catheter or urinate d. respiration
b. Emesis e. all is true
c. Stool

4. Fluid may be lost through Skin. It’s called :

a. Noticeable water lost c. obligatory lost
b. Insensible water lost d. voluntary lost

5. some uses / purposes of IVT as:except:

a. fluid and electrolyte replacement and blood transfusion therapy
b. drug administration,
c. ready access in emergency
d. parenteral nutrition
e. over hydration correction

6. Patients’ fluid requirements will increase: except

a. in hot weather, and with a pyrexia (high temperature)
b. if a urinary catheter is in situ
c. if constipated
d. client with puffy
e. if there is fluid loss from the gastro-intestinal tract, such as diarrhea, vomiting, or nasogastric or wound
drainage.

7. weak, irregular pulse, breathlessness and cough, expectorating white or pink frothy sputum
discomfort and restlessness, edema, particularly around ankles and sacrum, distended neck veins
raised / increase blood pressure
a. Fluid overload d. lack of electrolyte
b. over hydration e. insufficient fluid
c. A and b is true

8.This isotonic fluid provides fluid replacement without disturbing the electrolyte balance and provides energy
a. 5% dextrose in water c. lactated ringer
b. Normal saline d. normal saline in water

9. substances may be used to expand intravascular volume, and plasma volume such as: ecept
a. blood and its derivatives
b. artificial colloids such as dextrans,
c. hydroxyethyl starch (HES) and gelatin derivatives.
d. lactated ringered

10. patients who are temporarily unable to eat so, the infusion solution can be used :
a. dextrose 10% d. sodium chloride 0,9 %
b. dextrose 20% e. potassium chloride 10 %
c. A and B is true
11. cannula has slipped out of the vein or the vein has collapsed, causing a blockage and backflow of fluid into the
interstitial spaces is called :
a. Infiltration c. speed shock
b. Bacteraemia d. phlebitis

12. Septicaemia is condition when :

a. pathogenic bacterial toxins in the blood. C. blood clot in blood
b. bacteria in blood d. air bubble in blood

13. Caused by the rapid infusion of an IV drug resulting in a toxic blood concentration.
a. allergic reaction c. Circulatory overload
b. speed shock d. Emboli

14. Suitable diagnoses for dehydration :

a. alteration of breathing pattern related to foreign material occlude the airway
b. Discomfort related to chest pain
c. impairment of verbal communication
d. dehydration related to prolonged diarrhea indicated by bad skin turgor, weak, rapid and weak
pulse, sunken eye lids
e. lack of body fluid related to excessive bleeding. Indicated by CRT less than 3 second, pallor,
rapid and weak pulse

case I : Mr. Elliot, 53 Years old, receive IV therapy for fluid replacement for RL 20 drops per minute.
Nurse on duty will change the IV back for the second IV back and found the following
condition : P; 110 x / I, BP : 90 / 60 mmHg, RR: 28x/I, T : 37 0 C. Patient complained of Flushed
face, headache, dizziness, chest tightness, tachycardia/ rapid pulse and hypotension.

15. above Condition is indicated that …….happened :

a. allergic reaction c. Circulatory overload
b. speed shock d. Emboli

16. what is the suitable management for above case :

a. Stop infusion. Provide symptomatic relief, e.g. sitting up, oxygen therapy. Take vital signs. May need to
be given an antidote. Inform medical staff. Prevent by administering through a pump, burette or by syringe
driver.
b. Discontinue infusion immediately. Call for urgent assistance. Take vital signs. Maintain airway.
Administer epinephrine according to local policy. Prevent by taking a thorough history of allergy, and
monitor patient closely when giving potential allergens
c. Stop infusion, change administration set. Prevent by checking drug compatibility before administration.
Inform medical staff.
d. Stop IV. Call for assistance. Take vital signs. Turn patient onto left-hand side to encourage air to rise into
the right atrium. If cannula end is visible attempt to retrieve it.
e. Discontinue IV, send the cannula for Microscopy Culture and Sensitivity. Use smallest possible cannula to
reduce local irritation. Prevention includes careful aseptic site preparation and sterile dressing. Change
cannula, dressing and administration set every 48–72 hours. Monitor temperature and pulse every 4 hours
for early detection.

Case II : 3 days after infusion insertion of infusion on mr. Elliot, nurse on duty find : Swelling, inflammation,
redness, tense and hard vein (induration), possibly purulent discharge at cannula exit site. On laboratory
result obtain WBC ( white blood cells count ) : 13000.

17. base on above case, what happened to Mr. Elliot :

a. Phlebitis c. Circulatory overload
b. speed shock d. Emboli

18. What is the probably causes of above case ?

a. The inner lining of the vein is irritated by: chemical such as a drug, or acidic infusion such as potassium
chloride, physical irritation from the type of cannula used, the poor placement of a cannula
b. , too many attempts at cannulation, or bandaging or splinting too tightly or in an abnormal position
c. mechanical irritation from poor fixation. Once inflamed the vein may then become infected.
d. too much fluid has been infused and the patient is not able to disperse it naturally

19. what does nurse should do to handle this problems ?

Stop infusion. Provide symptomatic relief, e.g. sitting up, oxygen therapy. Take vital signs. May need to be
given an antidote. Inform medical staff. Prevent by administering through a pump, burette or by syringe
driver.
 b. Discontinue infusion immediately. Call for urgent assistance. Take vital signs. Maintain airway.
Administer epinephrine according to local policy. Prevent by taking a thorough history of allergy, and
monitor patient closely when giving potential allergens
c. Stop infusion, change administration set. Prevent by checking drug compatibility before administration.
Inform medical staff.
d. Stop IV. Call for assistance. Take vital signs. Turn patient onto left-hand side to encourage air to rise into
the right atrium. If cannula end is visible attempt to retrieve it.
e. Discontinue IV, send the cannula for Microscopy Culture and Sensitivity. Use smallest possible cannula to
reduce local irritation. Prevention includes careful aseptic site preparation and sterile dressing. Change
cannula, dressing and administration set every 48–72 hours. Monitor temperature and pulse every 4 hours
for early detection.

20. when a foreign body enters the circulation and travels until it occludes a small vessel:is called:
a. emboli c. thrombophlebitis
b. phlebitis d. induration

21. probably causes of dehydration are : except ;

a. prolonged vomit d. excessive fluid gain
b. certain disease e. bleeding
c. lack fluid intake

22. fluid can be eliminated through :abnormal ways except:

a. urine or feces d. orally, drinks or food
b. WSD, Wound drainage e. naso Gastric tube, emesis,
c. surgical pad, drain,

case III :
Mrs. Anne , 38 years old was admitted to hospital with long excessive bleeding. She need fluid replacement for fluid
and blood lost. Doctor suggested to insert Sodium chloride and HES 500 ml/8 hours
Nurse try to administer the infusion. The blood vessels invisible, because of constriction of vein. Nurse try to
administer it all the way to cover the blood and fluid need. She attempts many times for cannulation or insert the IV
chateter. And Splint it well because she afraid of dislocation occurred. Few Hours after the insertion Mrs. Anne
Complained of numbness, pain in her right arm, tingling.

23. what happened with Mrs. Anne ;

a. Phlebitis c. Circulatory overload
b. speed shock d. nerve injury

24. what is the probable cause :except

a. infiltration
b. poor dressing procedures around insertion site
c. too many attempts at cannulation, or
d. bandaging or splinting too tightly or in an abnormal position
e. poor location of cannula,

25. what is HES stand for :

a. hydroxyethyl starch c. heddon ethylence starch
b. hyper extra sell d. high extract sell

26. what is HES for ?

a. To expand intravascular volume c. to increase blood perfusion
b. to increase extra vascular volume d. to decrease superficial tense

27. nurse on duty need to adjust the IV flow for :

a. 21 ( dpm )drops/minute c. 30 dpm
b. 41 ( dpm )drops/minute d. 24 dpm

Cross match :
1.tolong berguling ke sisi kiri a. immerse your feet in this basin
2. berbaring telentang ( supine position ) b. lay onto your tummy
3. Prone position c.clench your fingers / make a fist
4. dorsal recumbent d.Lay flat on your back
5. rendam kaki anda pada kom ini e. lay flat on your back and flex your both knee
6. kepalkan jari- jari anda f. Roll your body to right site
7. g. Extent your elbow
8. luruskan lengan anda h. take your shirt off
9.melihat ke atas i. lift your right leg
10. angkat tangan anda j. raise your arm
11. semi fowler k. look upward
12. buka baju anda I will Raise your head level for 45 degree
13. angkat kaki anda m. wriggling your fingers
14. gulung lengan baju anda keatas n. spread your fingers
15. melangkah ke sini o. step up over here
16. tarik nafas dalam p. roll your sleeve up
17. lebarkan jari anda q. can you feel sensation on your leg ?
18.bisakah anda merasakan rasa pada kaki r. take a deep breath
anda?
19. gerakkan kaki anda s. move your leg
20. hindari luka dari basah t. avoid wound from getting wet