How to Write an Order for 500 mL Normal Saline Wide Open
For an older adult with orthostatic hypotension, write the order as: "Normal Saline 500 mL IV bolus, administer as rapidly as possible (wide open/push dose)" or "0.9% Sodium Chloride 500 mL IV bolus STAT, infuse over 5-10 minutes."
Order Components and Rationale
Essential Elements to Include
Specify the exact volume: Write "500 mL" or "0.5 L" to avoid confusion 1
Use precise fluid terminology: "Normal Saline" or "0.9% Sodium Chloride" or "NS" are all acceptable 1
Indicate administration speed: Use terms like "bolus," "wide open," "rapid infusion," or "infuse over 5-10 minutes" to communicate urgency 1
Route specification: Always include "IV" or "intravenous" 1
Sample Order Formats
Option 1 (Most explicit): "0.9% Sodium Chloride 500 mL IV bolus, administer wide open (as rapidly as possible), STAT"
Option 2 (Time-based): "Normal Saline 500 mL IV push, infuse over 5-10 minutes"
Option 3 (Rate-based): "NS 500 mL IV bolus at maximum infusion rate"
Clinical Context for Orthostatic Hypotension
When Fluid Boluses Are Appropriate
In orthostatic hypotension with acute symptomatic hypotension, small boluses of 5-10 mL/kg (approximately 350-700 mL in a 70 kg adult) are reasonable initial volumes 1
For moderate hypotension in older adults, 500 mL represents a conservative bolus that minimizes risk of volume overload while providing symptomatic relief 2, 3, 4
Oral hydration with salt supplementation is the mainstay of chronic orthostatic hypotension management, but IV boluses can be used for acute symptomatic episodes 5
Important Caveats for Older Adults
Avoid excessive volumes: Older adults with orthostatic hypotension may have underlying cardiac dysfunction or autonomic failure, making them more susceptible to fluid overload 1, 2
Monitor for supine hypertension: Many patients with neurogenic orthostatic hypotension develop severe supine hypertension, which can be exacerbated by aggressive fluid administration 2, 4
Assess cardiac tolerance: If the patient has known heart failure or significant cardiac disease, consider smaller boluses (250-300 mL) initially 1
Common Pitfalls to Avoid
Don't write "bolus 500 mL NS" without specifying IV route - this can lead to confusion about administration method 1
Avoid vague terms like "give quickly" - use specific language like "wide open," "rapid infusion," or specify a time frame (5-10 minutes) 1
Don't assume nursing staff will interpret "wide open" the same way - if you want maximum infusion rate, state "infuse as rapidly as possible" or "maximum infusion rate" 1
Remember that "wide open" typically means gravity-driven flow without rate restriction, which in practice delivers approximately 500 mL over 5-15 minutes depending on IV catheter size and patient venous pressure 1
Alternative Approaches for Chronic Management
For ongoing orthostatic hypotension management, oral salt supplementation (6-10 grams daily) and increased fluid intake (2-3 liters daily) are preferred over repeated IV boluses 2, 3, 5
Pharmacologic agents like midodrine or droxidopa should be considered for patients requiring frequent symptomatic interventions 3, 4
Physical countermaneuvers (leg crossing, squatting) and compression garments provide non-pharmacologic alternatives to fluid boluses for symptom management 2, 3, 4