FLUID VOLUME DISTURBANCES

FLUID VOLUME DISTURBANCES

ISOTONIC a. Extracellular fluid volume deficit b. Extracellular fluid volume excess
OSMOLAR a. Dehydration b. Water excess

Isotonic imbalances
- Water and electrolytes (sodium) are retained in isotonic proportions

Osmolar imbalances
- Losses or gains of water only

1. Extracellular Fluid volume deficit (hypovolemia)

- Loss of ECF volume exceeds the intake of fluid - Ratio of electrolytes to water remain the same

Causes:
1. Abnormal loss of body fluids
e.g. vomiting, diarrhea, sweating, hemorrhage, 3rd spacing, polyuria

2. oral intake
Neurologic problems thirst sensation Nausea Inability to gain access to fluids

s/sx

Acute weight loss skin turgor, dry skin and mucous membranes Oliguria, Thirst temp Muscle weakness, cramps Delayed capillary refill Postural hypotension tachycardia

(hypovolemic shock)

Cool, clammy skin from vasoconstriction CVP Weak, thready or absent pulse LOC

Management:
Laboratories Hct, S. Osm. U. Sp. Gr. K+ and Na+ levels
may vary according to underlying disorder Normal crea, BUN

1. Fluid replacement IV fluids: isotonic, followed by hypotonic Blood transfusion for hemorrhage 2. Vasopressors for shock: NE or dopamine 3. O2 as needed for decreased tissue perfusion

Nursing management
1. Prevent fld. vol. deficit: identify patients at risk 2. Monitor fluid status - MIO - Daily wt. - V/S pulse, postural BP(report for 25 mmHg systole) - Skin turgor and mucous membrane status - U. Sp. Gr. - Monitor mental status for s/sx of tissue perfusion

3. Correct fluid volume deficiency - Offer fluids at regular intervals; take note of patients likes and dislikes, and type of fluid lost - Offer antiemetics if with nausea - Maintain patent IV - Administer fluids, vasopressors, and blood a.d.

4. Prevent complications Frequent turning and skin and oral care Monitor for s/sx of fluid overload secondary to fluid replacement

2. Fluid volume excess (hypervolemia)

Isotonic expansion of ECF caused by abnormal expansion of Na+ and water in isotonic proportions May be in intravascular or interstitial space

causes
Fluid overload

Overinfusion of fluids

Diminished homeostatic mechanisms

Excessive Na+ or other solutes intake Use of plasma proteins Obstruction of lymph channels

Heart failure, renal failure, liver failure

Foods, hypertonic and Na+-containing fluids

JVD Crackles HPN Tachycardia, with full bounding pulse Acute in wt S/SX UO SOB Wheezing, RR Edema: dependent, ascites, pulmonary

LABS
Normal S. Na+ (Hemodilution) BUN, Hct CXR- pulmonary congestion/effusion Low S. K+, BUN

MANAGEMENT
Relieve underlying cause
E.g. d/c Na+containing IV fluids

Pharmacologic therapy
Mild to moderate thiazide diuretics Severe loop diuretics Lanoxin for CHF Morphine for pulmonary edema ACEI

Symptomatic treatment

Hemodialysis and peritoneal dialysis Oxygen administration Nutritional therapy

NUTRITIONAL THERAPY
Fluid restriction Na+ restriction (Normal intake : 6-15g/day) mild 4-5 g/day moderate 2 g/day severe 0.5g/d Substitute flavorings with lemon juice, onions, garlic Check labels CHON intake for those with low serum CHON

Nursing management
1. Prevent fluid volume excess Encourage adherence to Na+-restricted diet
2. Detect and control fluid volume excess

Monitor:wt, BP, breath sounds, edema (peripheral, dependent) Strict MIO

Control FVE:
- Rest to hasten diuresis; avoid prolonged standing - Elevate LEs, except in severe edema - Institute fluid and Na+ restriction as indicated
- Cold fluids to thirst sensation

- Monitor response to diuretics and IV flow rate

- Use infusion pumps

3. Reduce complications
Regular turning and positioning to prevent skin breakdown - Keep patients heel off the matress Monitor serum electrolytes if on diuretics Elevate HOB 30-45 degrees to venous return

OSMOLAR IMBALANCES 3. Intracellular fluid volume deficit (dehydration)

Loss of water more than Na+ ECF hypertonic, draws fluid out of cells

causes
1. intake of water 2. Excess loss of water without loss of solutes 3. Increased solute intake without sufficient water 4. Excess acummulation of solutes secondary to a dse/condition Dysphagia, stroke, coma, debilitated, NPO status Tachypnea, diaphoresis, DI, watery diarrhea Hypertonic fluid infusion; TPN

Hyperglycemia, DKA

 Wt loss Thirst

s/sx
Weakness Poor skin turgor Dry, flushed skin temp Sunken eyeballs Oliguria (except for osmotic diuresis, DI) Dry, cracked tongue tears CNS: confusion, restlessness, delirium; may lead to cerebral hemorrhage and coma

 Severe
Circulatory collapse tachycardia hypotension lethargy, coma

Labs
(hemoconcentration)

U. Sp Gr. S. Na+ S. Osm.

Management

1. Replace fluids
Hypotonic, low- Na+ flds (avoid hypertonic solutions)

2. Treat underlying cause

Vasopressin for DI

Nursing management
1. Prevent DHN: identify and monitor pts at risk
MIO, V/S, wt, LOC,

2. Replace fluids
p.o. for mild moderate losses Administer hypotonic IV solutions a.d. - @ slow rate to prevent cerebral edema

3. Ensure pt safety
Side rails up

4.Prevent skin breakdown

- Skin and mouth care

4. Intracellular fluid volume excess (water intoxication)

More sodium lost in ECF than water Water moves out of ECF into cells

 Hyponatremia Excess intake of electrolyte-free fld

causes

Psychogenic polydipsia, tap water enemas, use hypotonic fluids for irrigation, overinfusion of hypotonic fluids SIADH, oat-cell lung CA, stress heart failure, renal failure Diuretic therapy w/ low salt intake

ADH secretion

or inadequate output of urine

s/sx (associated with ECFVE)

Sudden wt gain Brain easily absorbs hypotonic fluids Intracellular edema ICP:

confusion and disorientation headache, N/V muscle weakness/ twitching SZ late signs: pupillary changes, bradycardia (slow, bounding pulse), widened pulse pressure

Management
Labs 1. ICP

S. S. Osm Hct hypoproteinemia

Na+

Osmotic diuretics Corticosteroids Restrict oral and parenteral fluids Avoid hypotonic solns until S. NA+ normalizes Hypertonic solutions in severe cases

2. Identify and treat cause

Nursing management
1. Monitor
a. neurologic status: LOC, V/S, reflexes, pupillary changes; refer for any changes b. Fluid status : MIO, wts, laboratory results (S. Na+, S. Osm.)

2. Restrict fluids as ordered 3. administer hypo- or hypertonic fluids carefully 4. Monitor infusion rates carefully

5. Irrigate NGT with NSS (use of hypotonic flds

may lead to fluid volume excess)

6. Provide safe envt and SZ precautions if with behavioral changes 7. Monitor patients who are taking large amounts of water p.o., rectally, or IV for s/sx of water intoxication

5. Third space fluid shift

Fluid shifts into interstitial space and remains there

Other potential spaces: pleural space, pericardial space peritoneum

Reflects inability of lymphatic system to circulate a manifestation, not a disease Acute and serious problem

cause
hydrostatic pressure

Rapid fluid administration, fluid overload

capillary permeability plasma CHONS

Venous obstruction at capillary level Nonfunctional lymphatic drainage

Inflammatory or allergic reactions, sepsis

Liver/kidney dse, burns, malnutrition Venous thrombosis Post-removal of lymph nodes

2 phases of fluid shift

1. Vascular to interstitial
(risk for hypovolemia and vascular collapse)

s/sx
No change in wt pallor, cool extremities, oliguria; weak, rapid pulse; BP; LOC s/sx of organ or nerve compression BUN, Hct, Na+, urine Sp. Gr.

2. Interstitial to vascular once capillary has healed

(risk for fld vol excess, CHF, hypokalemia)

Bounding pulse, crackles, engorgement of veins in periphery, JVD, HPN Hct, BUN

Management
1. Identify and tx underlying cause 2. Pericardiocentesis, thoracentesis, paracentesis to remove fluid 3. Restore fluids
a. Isotonic fld to replace intravascular volume - IV infusion will not resolve the problem b. Albumin (once capillary has healed) to promote restoration of oncotic pressure -

Nursing management
1. Monitor v/s q hr if with shock-like symptoms 2. Monitor IV fluid replacement needs
Monitor for s/sx of hypervolemia

3. Measure abdominal girth q8hrs, leg circumference 4. Assess peripheral pulses 5. Prevent skin breakdown 6. MIO qhr; report if UO <0.5ml/kg/hr for 2 consecutive hours 7. Monitor plasma BUN and crea; urine Sp. Gr. and osm.