Fluid ImbalancesFluid Imbalances

Peggy D. JohndrowPeggy D. Johndrow

20092009

Fluid Movement Between ECF & ICFFluid Movement Between ECF & ICF

Water deficit (increased ECF) is associated with symptoms that result from cell shrinkage as water is pulled into vascular system

Water excess (decreased ECF) develops from gain or retention of excess water

Fluid Spacing

First spacing Normal distribution of fluid in ICF and ECF

Second spacing Abnormal accumulation of interstitial fluid

Third spacing Fluid accumulation in part of body where it is

not easily exchanged with ECF

Differential Assessment ECF VolumeDifferential Assessment ECF Volume

Imbalances in ECF VolumeImbalances in ECF Volume

Extracellular Fluid Volume ImbalancesExtracellular Fluid Volume Imbalances

Hypovolemia can occur with loss of normal Hypovolemia can occur with loss of normal body fluids (diarrhea, fistula drainage, body fluids (diarrhea, fistula drainage, hemorrhage), decreased intake, or hemorrhage), decreased intake, or plasma-to-interstitial fluid shiftplasma-to-interstitial fluid shift

Hypervolemia may result from excessive Hypervolemia may result from excessive intake of fluids, abnormal retention of intake of fluids, abnormal retention of fluids (CHF), or interstitial-to-plasma fluid fluids (CHF), or interstitial-to-plasma fluid shiftshift

ECF Imbalances ManagementECF Imbalances Management

Treatment hypovolemia is balanced IV Treatment hypovolemia is balanced IV solutions, isotonic chloride, or bloodsolutions, isotonic chloride, or blood

Treatment hypervolemia is use of Treatment hypervolemia is use of diuretics, fluid restriction, and sodium diuretics, fluid restriction, and sodium restrictionrestriction

Nursing ManagementNursing Management

Hypervolemia:Hypervolemia: Excess fluid volumeExcess fluid volume Ineffective airway clearanceIneffective airway clearance Risk for impaired skin integrityRisk for impaired skin integrity Disturbed body imageDisturbed body image Potential complications: pulmonary edema, Potential complications: pulmonary edema,

ascitesascites

Nursing ManagementNursing Management

HypovolemiaHypovolemia Deficient fluid volumeDeficient fluid volume Decreased cardiac outputDecreased cardiac output Potential complication: hypovolemic Potential complication: hypovolemic

shockshock

Nursing ImplementationNursing Implementation

I&OI&O Monitor cardiovascular changesMonitor cardiovascular changes Assess respiratory status and monitor changesAssess respiratory status and monitor changes Daily weightsDaily weights Skin assessmentSkin assessment Neurologic functionNeurologic function

LOCLOC PERLAPERLA Voluntary movement of extremitiesVoluntary movement of extremities Muscle strengthMuscle strength ReflexesReflexes

Protein Imbalances

Plasma proteins, particularly albumin, are significant determinants of plasma volume

Hyperproteinemia is rare, but occurs with dehydration-induced hemoconcentration

Hypoproteinemia Caused by

Anorexia Malnutrition Starvation Fad dieting Poorly balanced vegetarian diets Poor absorption in certain GI malabsorptive Poor absorption in certain GI malabsorptive

diseasesdiseases Protein can shift out of intravascular space Protein can shift out of intravascular space

with inflammationwith inflammation Hemorrhage Hemorrhage Nephrotic syndromeNephrotic syndrome

Hypoproteinemia Clinical Manifestations

EdemaEdema Slow healingSlow healing AnorexiaAnorexia FatigueFatigue AnemiaAnemia Muscle loss Muscle loss AscitesAscites

Hypoproteinemia Management

High-carbohydrate, high-protein dietHigh-carbohydrate, high-protein diet Dietary protein supplementsDietary protein supplements Enteral nutrition or total parenteral Enteral nutrition or total parenteral

nutritionnutrition

IV Fluids Purposes

Maintenance- when oral intake not adequate Replacement- when losses have occurred

IV fluids will cause electrolyte imbalances if not corrected

Imbalances classified as deficits or excesses

Sodium plays major role in homeostasis of ECF

D5W Isotonic Provides 170 kcal/L Free water

Moves into ICF Increases renal solute excretion

Prevents ketosis Supports edema formation Decreased chance of IV fluid overload Usually compatible with medications

Normal Saline (NS)

Isotonic Isotonic No caloriesNo calories More NaCl than ECFMore NaCl than ECF 30% stays in intravascular (IV) (most)30% stays in intravascular (IV) (most)

70% moves out of IV70% moves out of IV

Expands IV volumeExpands IV volume Preferred fluid for immediate responsePreferred fluid for immediate response Risk for fluid overload higherRisk for fluid overload higher

Does not change ICF VolumeDoes not change ICF Volume Blood productsBlood products Compatible with most medicationsCompatible with most medications

Lactated Ringer’s

Isotonic More similar to plasma than NS

Has less Na Cl Has K, Ca, PO4, lactate (metabolized to

HCO3) Expands ECF, IV Common replacement fluid

D5 ½ NS Hypertonic Common maintenance fluid KCl added for maintenance or

replacement Provides calories

Prevents ketosis Moves into ICF Usually compatible with medications

D10W

Hypertonic Provides 340 kcal/L Free water Limit of dextrose concentration may be

infused peripherally

Plasma Expanders

Pull fluid into IV from interstitium Colloids

Packed RBCs Albumin Plasma