FLUID VOLUME DISTURBANCES

• ISOTONICa.Extracellular fluid volume deficitb.Extracellular fluid volume excess

• OSMOLARa.Dehydrationb.Water excess

Isotonic imbalances

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

Osmolar imbalances

- Losses or gains of water only

- 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 intakeNeurologic 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

Laboratories

↑ Hct, S. Osm.

↑ U. Sp. Gr.

K+ and Na+ levels may vary according to underlying disorder

Normal crea, ↑ BUN

Management:

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 patient’s 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 2. Fluid volume excess excess (hypervolemia)(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

• Diminished homeostatic mechanisms

• Excessive Na+ or other solutes intake

• Use of plasma proteins

• Obstruction of lymph channels

Overinfusion of fluids

Heart failure, renal failure, liver failure

Foods, hypertonic and Na+-containing fluids

• JVD• Crackles• HPN• Tachycardia, with

full bounding pulse• Acute ↑ in wt• ↑ UO• SOB• Wheezing, ↑ RR• Edema:

dependent, ascites, pulmonary

• Normal S. Na+

(Hemodilution)• ↓ BUN, Hct• CXR- pulmonary

congestion/effusion• Low S. K+, BUN

S/SX LABS

MANAGEMENT• Relieve

underlying cause– E.g. d/c Na+-

containing IV fluids

• Symptomatic treatment

• Pharmacologic therapy• Mild to moderate – thiazide

diuretics• Severe – loop diuretics• Lanoxin for CHF• Morphine for pulmonary edema• ACEI

• 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 patient’s heel off the matress

- Monitor serum electrolytes if on diuretics

- Elevate HOB 30-45 degrees to ↓ venous return

3. Intracellular 3. Intracellular fluid volume deficit fluid volume deficit (dehydration)(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

s/sx

• Wt loss• Thirst

• 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

Labs(hemoconcentration)

↑ U. Sp Gr.

↑ S. Na+

↑ S. Osm.

• Severe

Circulatory collapse

tachycardia

hypotension

lethargy, coma

Management

1. Replace fluidsHypotonic, low- Na+ flds

(avoid hypertonic solutions)

2. Treat underlying causeVasopressin for DI

Nursing management1. Prevent DHN: identify and monitor pts at risk

MIO, V/S, wt, LOC,

2. Replace fluidsp.o. for mild –moderate losses

Administer hypotonic IV solutions a.d.

- @ slow rate to prevent cerebral edema

3. Ensure pt safetySide rails up

4. Prevent skin breakdown- Skin and mouth care

4. Intracellular fluid 4. Intracellular fluid volume excess volume excess (water intoxication)(water intoxication)

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

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

• Hyponatremia

• Excess intake of electrolyte-free fld

• ↑ 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

Labs

↓ S. Na+

↓ S. Osm

↓ Hct

hypoproteinemia

Management

1.↓ ICP Osmotic diureticsCorticosteroidsRestrict oral and

parenteral fluids

Avoid hypotonic soln’s 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 env’t 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 5. Third space fluid shiftshift

• 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

• ↑ capillary permeability

• ↓ plasma CHONS

• Venous obstruction at capillary level

• Nonfunctional lymphatic drainage

Rapid fluid administration, fluid overload

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)

2. Interstitial to vascular once capillary has healed

(risk for fld vol excess, CHF, hypokalemia)

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.

• 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 fluidsa. 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.