Submitted to: Prof. Ronnie Tiamson Submitted by: Michaela Katrina A. Trinidad BSN III 2
Written Report Outline: Fluid Volume Deficit & Fluid Volume Excess 1. Short background about Fluids and Electrolytes 2. Fluid Volume Deficit a. Types of FVD b. Etiology c. Pathophysiology d. Clinical Manifestations e. Diagnostic and Laboratory Procedures f. Medical Management 3. Fluid Volume Excess a. Types of FVD b. Etiology c. Pathophysiology d. Clinical Manifestations e. Diagnostic and Laboratory Procedures f. Medical Management
FLUID AND ELECTROLYTES Normal Function Body fluids consist of intracellular and extracellular fluid. The intracellular fluid makes up about 2/3 of the body water. The extracellular fluid makes up the remainder and consists of: 1. Interstitial fluid - fluid between the cells. 2. Plasma and lymph - the intra-vascular fluid. 3. Cerebrospinal fluid - found in ventricles of brain and surrounding the brain and spinal cord. 4. G.I. tract fluids - gastric, pancreatic and intestinal juices. 5. Synovial fluid - found inside synovial joint capsules. 6. Eye and ear fluids - aqueous and vitreous humours, perilymph and endolymph. 7. Pleural, pericardial and peritoneal fluids. 8. Glomerular filtrate. One of the primary functions of the kidney is to regulate extracellular fluid pressure. There are two components of extracellular fluid pressure: 1. Hydrostatic (blood) pressure - Blood pressure depends on: a. The volume of the extracellular fluids. b. The diameter of the peripheral blood vessels.
2. Osmotic pressure - depends on the a. Levels of non-diffusing proteins in plasma and interstitial fluids. b. The concentration of electrolytes, especially Na+.
FLUID VOLUME DEFICIT Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal (GI) tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment is paramount to prevent potentially life-threatening hypovolemic shock. Elderly patients are more likely to develop fluid imbalances. Related Factors Inadequate fluid intake Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea) Failure of regulatory mechanisms Electrolyte and acid-base imbalances Increased metabolic rate (fever, infection) Fluid shifts (edema or effusions) Defining Characteristics Decreased urine output Concentrated urine Output greater than intake Sudden weight loss Decreased venous filling Hemoconcentration Increased serum sodium Hypotension Thirst Increased pulse rate Decreased skin turgor Dry mucous membranes Weakness Possible weight gain Changes in mental status Medical Management for Fluid Volume Deficit Traditional clear fluids are not appropriate for ORT. Many contain excessive concentrations of CHO and low concentrations of sodium. The inappropriate glucose-to-sodium ratio impairs water absorption, and the large osmotic load creates an osmotic diarrhea, further worsening the degree of dehydration. ORT for mild or moderate dehydration o Mild or moderate dehydration can usually be treated very effectively with ORT. o Vomiting is generally not a contraindication to ORT. If evidence of bowel obstruction, ileus, or acute abdomen is noted, then intravenous rehydration is indicated. o Calculate fluid deficit. Physical findings consistent with mild dehydration suggest a fluid deficit of 5% of body weight in infants and 3% in children. Moderate dehydration occurs with a fluid deficit of 5-10% in infants and 3-6% in children (see Table 1 and Table 2). The fluid deficit should be replaced over 4 hours. o The oral rehydration solution should be administered in small volumes very frequently to minimize gastric distention and reflex vomiting. Generally, 5 mL of oral rehydration solution every minute is well tolerated. Hourly intake and output should be recorded by the caregiver. As the child becomes rehydrated, vomiting often decreases and larger fluid volumes may be used. o If vomiting persists, infusion of oral rehydration solution via a nasogastric tube may be temporarily used to achieve rehydration. Intravenous fluid administration (20-30 mL/kg of isotonic sodium chloride 0.9% solution over 1-2 h) may also be used until oral rehydration is tolerated. According to a Cochrane systematic review, for every 25 children treated with ORT for dehydration, one fails and requires intravenous therapy. o Replace ongoing losses from stools and emesis (estimate volume and replace) in addition to replacing the calculated fluid deficit. o An age appropriate diet may be started as soon as the child is able to tolerate oral intake.
Severe dehydration o Laboratory evaluation and intravenous rehydration are required. The underlying cause of the dehydration must be determined and appropriately treated. o Phase 1 focuses on emergency management. Severe dehydration is characterized by a state of hypovolemic shock requiring rapid treatment. Initial management includes placement of an intravenous or intraosseous line and rapid administration of 20 mL/kg of an isotonic crystalloid (eg, lactated Ringer solution, 0.9% sodium chloride). Additional fluid boluses may be required depending on the severity of the dehydration. The child should be frequently reassessed to determine the response to treatment. As intravascular volume is replenished, tachycardia, capillary refill, urine output, and mental status all should improve. If improvement is not observed after 60 mL/kg of fluid administration, other etiologies of shock (eg, cardiac, anaphylactic, septic) should be considered. Hemodynamic monitoring and inotropic support may be indicated.
Pharmacologic management o Antidiarrheal agents are not recommended because of a high incidence of side effects including lethargy, respiratory depression, and coma. o Routine empiric antibiotics should be avoided and may worsen some specific diarrheal disease states (eg, hemolytic-uremic syndrome,Clostridium difficile). o Over-the-counter antiemetics are not recommended due to side effects including drowsiness and impaired oral rehydration. o In an emergency department study, ondansetron has been shown to decrease likelihood of vomiting, increase oral intake, and decrease emergency department length of stay but has not shown significant effects on hospitalization rates or long-term outcomes. [13]
o Dimenhydrinate, although used in Europe and Canada, has not been found to improve oral rehydration.
FLUID VOLUME EXCESS Fluid volume excess, or hypervolemia, occurs from an increase in total body sodium content and an increase in total body water. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in congestive heart failure (CHF), kidney failure, and liver failure. It may also be caused by excessive intake of sodium from foods, intravenous (IV) solutions, medications, or diagnostic contrast dyes. Hypervolemia may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of fluid and sodium restriction, and the use of diuretics. For acute cases dialysis may be required. Related Factors Excessive fluid intake Excessive sodium intake Renal insufficiency or failure Steroid therapy Low protein intake or malnutrition Decreased cardiac output; chronic or acute heart disease Head injury Liver disease Severe stress Hormonal disturbances Defining Characteristics Weight gain Edema Bounding pulses Shortness of breath; orthopnea Pulmonary congestion on x-ray Abnormal breath sounds: crackles (rales) Change in respiratory pattern Third heart sound S 3
Intake greater than output Decreased hemoglobin or hematocrit Increased blood pressure Increased central venous pressure (CVP) Increased pulmonary artery pressure (PAP) Jugular vein distention Change in mental status (lethargy or confusion) Oliguria Specific gravity changes Azotemia Change in electrolytes Restlessness and anxiety Hypervolemia: Pathologic Process Normally, the body can create processes with which it can compensate and relinquish fluid and electrolyte equilibrium. This is usually done with the help of hormones such as aldosterone, atrial natriuretic peptide (ANP) and antidiuretic hormone (ADH). These hormones cause the nephrons in the kidneys to release the essential water and sodium needed by the body. Hypervolemia may occur in instances where there is an elevation of intravascular volume levels. This may be due to shifts in fluids from the interstitium to plasma, reduced excretion of sodium and water, excessive intravenous fluids, and excessive retention of water and sodium from chronic renal stimuli attempting to conserve both.
An elevation of the extracellular fluid volume produces circulatory overload and subsequently, an abnormally amplified cardiac contractility, increased mean artery pressure (MAP), and an elevated capillary hydrostatic pressure. The latter, as a consequence, causes shifts of fluids to the interstitial space, and hence, producing edema.
If severe hypervolemia is at hand, or patient has a previous history if cardiac dysfunction, compensatory mechanisms may fail. Urinary excretion of sodium and water may fall short. Antidiuretic hormone and aldosterone may not be diminished from mean arterial pressure elevation. Hence, pulmonary edema and heart failure may prevail. Treatment and Management of Hypervolemia
The following are therapeutic interventions in the management of hypervolemia: Restriction of sodium and water intake. Monitor input of fluids, including that of oral, enteral and parenteral. Avoid foods with high sodium content. Diuretics may be given. Loop diuretics, such as furosemide, are recommended for heart failure and severe hypervolemia. To assess the severity of electrolyte loss and monitor the patients response to diuresis, his weight and his urine output must be regularly determined and monitored. Medications, like nitroglycerin and morphine, can be administered for dilatation of blood vessels and subsequent reduction of pulmonary congestion. Hydralazine and Captopril, afterload reduction medications, can also be given for relief of pulmonary edema Renal replacement therapies, such as hemodialysis and peritoneal dialysis, may be performed among patients with renal failure or those with severe hypervolemia. Continuous arteriovenous and venovenous hemoinfiltrations both aims for sufficient removal of excess fluids from those patients not necessitating dialysis. Other palliative measures comprise of antiembolism stockings to mobilize edema, oxygen inhalation, bed rest, and, of course, treatment of underlying cause of hypervolemia.[5, 6, 7] Expected Outcome Patient maintains adequate fluid volume and electrolyte balance as evidenced by: vital signs within normal limits, clear lung sounds, pulmonary congestion absent on x-ray, and resolution of edema.