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Fun with fluids.

Fluid balance is both a complex and content-laden topic that nursing students need to understand. It is the foundation for reasoning needed to think critically about patients and make decisions regarding care. Although numerous textbooks (Cupelli, 2013; Hinkle & Cheever, 2014; Kee, Paulanka, & Polek, 2010a, 2010b; LeMone, Burke, & Bauldoff, 2011), learning programs (Hinkle & Cheever, 2014; Kee, Paulanka, & Purnell, 2004), and article collections (Wolters Kluwer Health, LWW, 2014) exist about the importance of nurses' understanding of patients' fluid balance, articles, textbooks, or even learning programs that focus on the teaching and learning of such a complex topic rarely are found.

Literature Review

A web search and literature review in the following databases identified current teaching strategies used to facilitate nursing students' learning and application of fluid balance in their patients: Google, Google Scholar, CINAHL with Full Text, Ovid Nursing Full Text PLUS, ProQuest Education Journals, Summon, Academic Search, ERIC, and ProQuest. The search used various combinations of the terms active, teaching, strategy, nursing, education, fluids, electrolytes, and learning. Excluded were articles and research reports focused on learning strategies in fields other than nursing education, access to web sites or learning programs focused on topics not related to fluids and electrolytes, and passive learning strategies. Included were articles and research focused on active learning strategies in nursing education; web access to blogs, videos, and websites focused on mastery of fluid and electrolytes in nursing education; and textbooks and/or learning programs focused on fluid balance and electrolytes in nursing education.

Articles and Research Studies

Nursing students historically have struggled with learning a large amount of content in a short amount of time and turned to memorization as a learning tool (Bowles, 2006). Memorization serves no purpose when nursing students need to apply knowledge in a practical setting. Bowles recommended a student-centered learning environment that incorporates active-teaching strategies. Active-teaching strategies engage students in learning and promote critical thought, which is necessary in nursing practice.

According to Boctor (2013), millennial nursing students (born after 1982) prefer technology for learning and enjoy a hands-on, active approach to education. Games as an active learning strategy bring a deeper level of learning than passive strategies, enhance collaboration among students, allow immediate feedback, and promote critical thinking and reasoning. "Nursopardy" was created by Boctor to facilitate a review of topics in nursing fundamentals. Students responded positively to this game because it allowed them to engage and review a large amount of information with one activity.

Cupelli (2013) presented an active-teaching tool to assist nurse educators in designing their curriculum for fluids and electrolytes. The tool, which the instructor incorporated into lectures, provides a visual cue for learners. Cupelli described use of jars, marbles, water, and food coloring to simulate tonicity of intravenous (IV) solutions, and balloons to simulate cellular changes associated with the tonicity of fluid and fluid balance. These visual cues reinforce understanding of the content. In addition, this strategy facilitates active learning by promoting a classroom discussion about IV fluids, fluid volume excess, and fluid volume deficit. The author indicated she has used the tool effectively in lectures, with positive outcomes regarding her students' understanding of fluid and electrolytes.

Internet Resources

Use of the term fluid electrolyte learning program in a Google search revealed a large number of options that can be accessed by anyone to facilitate learning. Nursing students have access to YouTube, which contains lectures and animations to help facilitate learning. In addition, the Internet offers free access to blogs, Wikis, and links to downloadable applications for smart phones. McGraw Hill (McKinley & O'Loughlin, 2006; Raven, Johnson, Losos, & Singer, 2003) offers free access to biology animations that can be integrated into lectures. Wise-Online offers a free interactive learning exercise (Stroupe, 2004). Additional resources include tutors and flash cards. Source credibility may be a limitation for all of this information; sources should be evaluated by a prospective user.

Textbooks and Learning Programs

Textbooks are plentiful, and most nursing fundamentals and medical-surgical nursing books offer chapters dedicated to fluid balance, electrolytes, and acid-base balance. However, textbooks represent a passive approach to learning. Cost also may be a limitation. Kee and co-authors (2010a, 2010b) produced a simple yet comprehensive handbook and a study guide. In addition, the compact discs from Kee and colleagues (2004) and Hinkle (2014) offered more active approaches that include quizzes, videos links, animations, and case studies.

One common research theme is promotion of student engagement and learning through incorporation of active-teaching strategies (Boctor, 2013; Bowles, 2006; Cupelli, 2013; Stroupe, 2004). A great deal of the material available on the Internet and in textbooks and learning programs has limited activity, which in turn decreases the ability of students to engage in learning. Faced with teaching the complex topic of fluid balance to nursing students with no comprehensive learning program available, authors of this manuscript created an active teaching strategy called Fun with Fluids to promote knowledge retention and practical application.

Project Description

Fun with Fluids helps students understand fluid balance and intracellular volume shifts. Integrated into the nursing laboratory to help students with the practical application of theory, this product was developed to provide an active-learning environment that facilitates retention, comprehension, and application of knowledge.

During the first half of the semester in the authors' nursing education program, students participate in a variety of hands-on activities in the laboratory while they learn medication administration and intravenous skills. Content during the second half of the semester (concepts of fluids, electrolytes, and acid base) was passive and frankly boring for students. Authors tried to locate a learning program, game, or activity to keep students engaged; their lack of success led to creation of Fun with Fluids. It meets educational needs and engages all student learning styles through the incorporation of visualization, kinesthetics, and verbalization.


An 18 x 36 inch corkboard covered by a rendering of the capillary helps students visualize what occurs at the cellular level when a patient experiences fluid volume excess of deficit. See Figure 1, which depicts the following:

* Extracellular space/vascular space, intracellular space,

and interstitial space

* Arterial and venous ends of the capillary

* Three cell sizes: normal, shrunken, and swollen

* Hydrostatic and colloidal osmotic pressure

Weaving loom loops and pushpins, which simulate semi-permeable membranes, make borders among the extracellular space/vascular space, intracellular space, and interstitial spaces. Each colored pebble represents components of the cellular and vascular space, such as water, blood, albumin, sodium, glucose, and potassium (see Figure 2).

Kinesthetics and Verbalization

Nursing students use the corkboard and colored pebbles to depict the capillary in an isotonic state. They have learned about isotonicity from prerequisite courses (e.g., pathophysiology) and the didactic portion of the current course. Once their board is finished, students receive instructions to shift their pebbles to depict fluid volume deficit or excess. Students move pebbles among the extracellular space/vascular space, intracellular space, and interstitial spaces.


Students receive a study guide to complete while using the board. The study guide helps them identify what is happening in the body when fluid shifts, causes of the imbalance (e.g., chronic diseases such as heart failure, diabetes, alcoholism), expected signs and symptoms they would identify as nurses, and anticipated treatments for each imbalance. A two-page study guide is available to the faculty to help facilitate the discussion and reinforce the information.

The first page of the study guide includes four sections: physiology, causes, signs and symptoms, and treatments. Physiology explains what is happening in the body and includes the description of the volume and solute loss, osmotic pressure, and cell response. The second section discusses causes of the imbalance and describes patients who might present with this problem. The third section identifies signs and symptoms, with an emphasis on nursing assessments and abnormal findings. Treatments are reviewed in the final section. Students are provided information on types of medications, IV fluids, diet, and/or health care provider orders expected to correct this volume imbalance. The second page provides a blank copy of the corkboard, which students can use to sketch a picture of each volume imbalance. However, most students choose to take a picture with their phones rather create a drawing.

Application Strategies

Laboratory classes have approximately 14 students. Five corkboards and five sets of materials are available to accommodate this number of students. Each set of materials includes one container each of colored pebbles (red for blood, blue for water, clear for sodium, pink for potassium, green for glucose, amber for albumin, light blue for chloride). Divided into groups of two or three, students gather around a corkboard with their containers of pebbles. The laboratory instructor provides verbal instructions and circulates from group to group, so he or she does not need a corkboard.

The laboratory instructor begins with a detailed review of the activity and the materials. To understand the activity, students need to know the ranges in the vascular space that signify normal vascular volume. The vascular space (colored red on the corkboard) shows a division of three sections; normal vascular volume is the inner and middle section, vascular shrinkage is the inner section, and expansion is all three sections. Additionally, the vascular area of the board has labeled arterial and venous ends. Three cell sizes (colored yellow) are depicted and labeled as normal, shrunken, or swollen. Around and between the cells and vascular space is the blue interstitial space.


Once students understand the components of the board activity, they are instructed to construct the board in an isotonic state. The instructor should begin this activity with a blank Fun with Fluids board, which then is transformed by students into the isotonic state. This allows students to appreciate normal fluid balance and placement of fluid and electrolytes in the intracellular, interstitial, and intravascular compartments (see Figure 3).

To depict an isotonic state, students use normal vascular volume and the normal size cell. Students should be encouraged to use plenty of sodium and water in the vascular space when initially creating the board, which allows them to add or remove pebbles as fluid volume imbalances of excess and deficit are discussed. Sodium, water, blood, glucose, albumin, and a few potassium pebbles are placed in the vascular space. Potassium, glucose, and water are placed in the intracellular space. Finally, a small amount of water is placed in the interstitial space. The instructor can facilitate board set up and should circulate the room to check board accuracy. He or she then facilitates the discussion on the normal isotonic state.

The study guide does not contain written information about isotonicity; however, students can complete a rendering of this state on the second page of the study guide. Students then are instructed to shift the board to one of the volume imbalances, either deficit or excess. Deficit or excess imbalances can be reviewed in any order; however, beginning with iso-osmolar fluid volume deficit often is easiest for students to understand and helps them learn to use the board.

Fluid Volume Deficit

To change to iso-osmolar fluid volume deficit, students remove sodium and water pebbles from the vascular space. When the vascular space has decreased volume, they should shift the remaining pebbles to the innermost section of the vascular space. Because the loom loops function as semi-permeable membranes, students can push pebbles under the loops to the smaller vascular space. Once this is done, the instructor leads a discussion about what is happening at the cellular level. For example, is there a change in osmotic pressure? Would the cell size stay the same? Would the cell increase or decrease in size? This discussion helps students understand any osmotic pressure change and cell compensation for the vascular volume change. Students complete their study guide pages then return the board to an isotonic state, which reinforces the treatment to return the body to normal balance.

After the board is returned to a normal isotonic state, the instructor facilitates the next fluid imbalance. For example, the difference with hyperosmolar fluid volume deficit is either more loss of fluid than solute or more intake of solute than fluid. Students are instructed to remove water pebbles but not sodium from the board, or add sodium and not water, and shrink the vascular space to the smallest area. By making one of these changes, they are able to see the vascular space has an increased amount of solute but decreased amount of volume. The discussion then focuses on what happens with the osmotic pressure and the cell response. With the board, students see how increased solute or decreased volume leads to osmotic pressure increases in the vascular space and a shift of the fluid from the cell in the body's attempt to maintain vascular volume; the cell will shrink. Students move the water pebbles from the cells to the vascular space and move the pebbles for the cell components to the small cell on the board. Students are able to visualize how vascular changes affect the cells and how the body tries to compensate for the abnormality. Students complete their study guide pages and then return the board to an isotonic state.

Fluid Volume Excess

A similar process is followed for the remaining fluid volume imbalances, including extracellular fluid volume excess, plasma hydrostatic pressure, plasma colloid osmotic pressure, intracellular fluid volume excess, and extracellular fluid volume shift (phases 1 and 2). For each imbalance, the instructor facilitates the changes in the board that enable students to emphasize the differences between the imbalances and the changes occurring at the cellular level. Students complete their study guide pages following each excess imbalance and then return the board to an isotonic state. Discussion and completion of the accompanying study guide is an important component of the process. After completion of each study guide, the board always is returned to an isotonic state before moving to the next imbalance. This enables students to recognize what is normal and reinforces the body's desire for balance.

Observations and Reactions

Students' reactions have been positive. Students are engaged actively in using the board, and participate in discussion and completion of the study guide. Small groups allow students to work with friends and help each other through the process. Importantly, students like having an activity for laboratory. They appreciate having a visual representation of complex content that often is difficult to conceptualize. The exercise also offers a format to reinforce lecture content and provides students with a complete, concise study guide for the examination. The need for visual cues was reinforced by students' desire to use their phones to take pictures of the corkboard during the activity focusing on fluid imbalances.

Instructor use of real-life examples is very helpful. For example, during discussion of hyperosmolar fluid volume deficit, the example involved a person who ate a high-sodium meal from a local hamburger restaurant. Most students are familiar with the restaurant and enjoy the food, so they can relate to the discussion of signs, symptoms, and treatments. Students recognized their own thirst and decreased need to urinate after a high-sodium meal. This example related to the hyperosmolar state of excessive solute, and students saw the connection to the content. Using such examples also helps students stay engaged, and students provide other examples of experiences with other high-sodium meals.

A second example relates to intracellular fluid volume excess. The example used is the story of Jennifer Strange, who tried to win a Wii in a radio contest by drinking water and died from water intoxication (Clark & McHugh, 2009). This example illustrates dilution of solute in the vascular space caused by excess free water intake; osmotic pressure in the cell then increases, causing a shift of fluid to the cell and cell swelling. The resulting increase in intracranial pressure went untreated in this case. Such real-life examples reinforce cellular physiology, causes of the imbalance and related signs and symptoms, and effective treatments.


Fun with Fluids is a comprehensive, engaging, and useful tool for teaching fluid volume imbalances. The board's utilization over several years has evolved to the current successful process. The instructor is a facilitator of the process, guiding students through the board changes and study guide discussions. A strong benefit to the process is the ability for instructors to emphasize nursing care for each imbalance, including expected assessment findings.


Boctor, L. (2013). Active-learning strategies: The use of a game to reinforce learning in nursing education. A case study. Nurse Education in Practice, 13(2), 96-100. doi:10.1016/j.nepr.2012.07.010

Bowles, D. (2006). Active learning strategies ... not for the birds! International Journal of Nursing Education Scholarship, 3(1). doi:10.2202/1548-923X.1184

Clark, S., & McHugh, R. (2009). Jury rules against radio station after water-drinking contest kills Calif, mom. Retrieved from http://abc

Cupelli, L. (2013). Creative visual strategy to simplify fluid and electrolyte basics. Journal for Nurses in Professional Development, 29(3), 154. doi:10.1097/NND.0b013e3182938ade

Hinkle, J. (2014). Lippincott's course point prepU for Brunner & Suddarth's textbook of medical-surgical nursing (13th ed.). Philadelphia, PA: Lippincott, Williams, & Wilkins.

Hinkle, J., & Cheever, K. (2014). Brunner & Suddarth's textbook of medical-surgical nursing (13th ed.). Philadelphia PA: Lippincott Williams & Wilkins.

Kee, J., Paulanka, B., & Polek, C. (2010a). Fluids and electrolytes with clinical applications: A programmed approach (8th ed.). Clifton Park, NY: Delmar Cengage Learning.

Kee, J., Paulanka, B., & Polek, C. (2010b). Handbook of fluid, electrolyte, and acid-base imbalances (3rd ed.). Clifton Park, NY: Delmar Cengage Learning.

Kee, J., Paulanka, B., & Purnell, L. (2004). Fluids and electrolytes electronic learning program (2nd ed.). Clifton Park, NY: Delmar Cengage Learning.

LeMone, P, Burke, K., & Bauldoff, G. (2011). Medical-surgical nursing: Critical thinking in patient care (5th ed.). Upper Saddle River, NJ: Prentice Hall.

McKinley, M., & O'Loughlin, V.D. (Eds.). (2006). The cell: Basic unit of structure and function. In Human anatomy. New York, NY: McGraw Hill. Retrieved from 0072495855/student_view0/chapter2/index.html

Raven, R, Johnson, G., Losos, J., & Singer, S. (Eds.). (2003). Biology (7th ed.). Chapter animations. New York, NY: McGraw Hill. Retrieved from 0072437316/120060/ravenanimation.html

Stroupe, P. (2004). Fluid and electrolytes. Retrieved from

Wolters Kluwer Health, LWW. (2014). Focus on: Fluids and electrolytes. Retrieved from pageID=15

Teresa Kisch, MSN, RN, CMSRN, is Assistant Professor of Nursing, Aurora University School of Nursing, Aurora, IL.

Janet LoVerde, MSN, RN, is Assistant Professor of Nursing, Aurora University School of Nursing, Aurora, IL.


Fun with Fluids Legend

Fluid/Electrolyte    Pebble Color

Water                Dark Blue
Blood                Red
Sodium               Clear
Potassium            Lt. Pink
Protein              Clear Brown
Glucose              Light Green
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Title Annotation:Nurses as Educators
Author:Kisch, Teresa; LoVerde, Janet
Publication:MedSurg Nursing
Article Type:Report
Geographic Code:1U2NY
Date:May 1, 2015
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