Knowing Your IVFs

1. "Hypotonic" (< 270 mmol/L)

Provides more water than electrolytes, diluting the
ECF. Movement of water from the ECF to the cells
(ICF). Examples: 0.45% saline; D5W (after the
dextrose is metabolized). Provide free water for cellular
hydration and renal excretion (hydrate the kidneys). Not
for clients with increased ICP or third-space fluid shifts.
Hypotonic solutions are used to provide free water and
treat cellular dehydration. Hypotonic solutions provide
greater amount of water than electrolytes, and have
decreased osmotic pressure. This causes an increase
in intracellular fluid. The fluid leaves the intravascular
space and rehydrates the cells. These solutions also
promote waste elimination by the kidneys. Out of one
liter of fluid, only about 85 ml stay in the intravascular
space. Maintenance fluids are usually hypotonic
solutions, because normal daily losses are hypotonic.
D5W is an example of a hypotonic solution. It does not
provide any electrolytes. It is isotonic on initial
administration. Once the dextrose is metabolized,
however, (in about 5 minutes), it provides free water for
renal excretion and promptly leaves the intravascular
space to expand the intracellular fluid volume. It also
provides 170 calories/L for metabolism. Hypotonic
solutions should not be administered to patients with
increased intracranial pressure because it can increase
cerebral edema. Also, not for clients with third-space
fluid shift.
Hypotonic solutions should be given at a slower rate
than isotonic solutions. One of the best guides to a safe
rate of flow is the reaction of the patient. Therefore, the
nurse must observe signs and symptoms carefully
(such as shortness of breath, dyspnea, coughing,
cyanosis, increased respiratory rateall symptoms of
pulmonary edema).

2. "Isotonic" (270-300 mmol/L)
Expands only the ECF. No net loss or gain from the
ICF. Fluid replacement for a patient with an ECF
volume deficit. Examples: NS (0.9% saline), LR. Used
to expand vascular volume.Assess for hypervolemia
(bounding pulse, SOB). An isotonic solution stays in the
extracellular compartment and is used to expand the
intravascular volume. 1 liter isotonic IV solution will
expand the intravascular space by about 250 mL.
Approximately 400 cc of isotonic IV fluid (NS, LR) is
required to compensate for each 100 cc of blood loss.
Since isotonic solutions remain in the extracellular
space, assess clients carefully for signs of
hypervolemia such as bounding pulse and shortness of
breath.
0.9% saline is a percentage of milligrams per deciliter
(100 ml). Normal saline is 0.9 grams (900 mg) of NaCl
in 100 ml of water. Normal saline is a balanced
electrolyte solution. NS = 154 mEq/L Na+ and 154
mEq/L Cl-
Lactated Ringers solution is an isotonic electrolyte
solution. It contains sodium, chloride, potassium,
calcium and lactate in water. LR = 130 mEq/L Na+, 4
mEq/L K+, 109 mEq/L Cl-, 28 mEq/L lactate, 3 mEq/L
Ca++
Lactate is oxidized by the liver to bicarbonate. LR is
contraindicated in severe metabolic acidosis or
alkalosis, in liver disease, anorexia, or anoxic states.
Lactic acidosis may occur in association with an
underlying disease, such as diabetes mellitus, severe
iron-deficiency anemia, liver diseases, alcoholic
ketoacidosis, pancreatitis, malignancy (eg, leukemias,
lymphomas, lung cancer), alkalosis, infections (malaria,
cholera), renal failure, pheochromocytoma, thiamine
deficiency, short gut syndrome and other carbohydrate
malabsorption syndromes. Lactated ringers should also
be avoided in these circumstances.

3. "Hypertonic" (>300 mmol/L)
Raises the osmolarity of ECF and expands it. Draws
water out of the cells (ICF) into the ECF.Examples:
D5 NS, D5NS, D5LR, 3% NaCl, TPN.
Not for clients with kidney or heart disease or who are
dehydrated. Assess for hypervolemia. Hypertonic
solutions draw water out of the intracellular and
interstitial compartments into the vascular
compartment, expanding vascular volume. Hypertonic
solutions must be administered slowly and with
extreme caution, because they may cause dangerous
intravascular volume overload and pulmonary edema.
These require frequent monitoring of blood pressure,
lung sounds, and serum sodium levels. Do not
administer to clients with kidney or heart disease or
clients who are dehydrated. Watch for signs of
hypervolemia.

Guidelines for Administration of IV Fluids:
Give isotonic fluids: (NS, LR) for isotonic dehydration.
Give hypotonic fluids: (0.45% saline, D5W) SLOWLY to
treat hypertonic dehydration.
Give NS or hypertonic fluids: (D5/0.9% saline, D5/LR)
to treat hypotonic dehydration.