Fluid Volume Deficit (Hypovolemia)

I. Description of the disease/condition:

Occurs when loss of extracellular fluid volume exceeds the intake of fluid. It occurs when water and electrolytes are lost in the same proportion as they exist in normal body fluids, so that the ratio of serum electrolytes to water remains the same. ( Med. Surg. Nsg. By Smeltzer)

Is a state of decreased blood volume; more specifically, decrease in volume of blood plasma. (http://en.wikipedia.org/wiki/Hypovolemia)

Means low blood volume. "Hypo" means low, "vol" is for volume, and "emia" refers to blood. http://coloncancer.about.com/od/glossaries/g/Hypovolemia.htm)

II. Risk Factors

Severe bleeding (from internal or external injuries) Severe vomiting Dehydration Severe burns Blood donation Excessive sweating Severe diarrhea Surgery

III. Assessment Findings/Clinical Manifestations

Tachycardia Decreased blood pressure Oliguria Tachypnea Dizziness Poor skin turgor Hyperthermia Cool clammy skin Delayed capillary refill Confusion Thirst Fatigue Muscle weakness Cramps

IV. Diagnostic Test results

BUN to Creatinine ratioNormal value: 10:1-15:1Hypovolemia: 20:1

Renal failure or decreased renal perfusion

Blood urea nitrogen (BUN)Normal value: 5-20 mg/dlHypovolemia: elavated

Dehydration, Renal failure or decreased renal perfusion

HematocritNormal value: Males: 42-52% Females: 35-47%Hypovolemia: elevated

RBCs become suspended in a decreased plasma volume

Urine specific gravityNormal value: 1.016-1.022Hypovolemia: elevated

In attempt to conserve water

Urine osmolalityNormal values: 250-900 mOsm/kg H2OHypovolemia: elevated

Kidneys try to compensate by conserving water

Serum SodiumNormal Value: 135-145 mEq/LHypovolemia: reduced or elevated

Hyponatremia: occurs with increased thirst and ADH release. Low total body water and sodium levels may be due to dehydration, vomiting, diarrhea, over diuresis, or ketonuria.

Hypernatremia: If the amount of fluid in your body is low, you may have fluid loss due to

excessive sweating, diarrhea, use of diuretics, or burns. If your total body water is normal, high sodium levels may be due diabetes

insipidus (too little of the hormone vasopressin).

Serum potassiumNormal value: 3.5-5.3 mEq/LHypovolemia: reduced or elevated

Hypokalemia: GI and renal losses; Chronic diarrhea, vomiting

Hyperkalemia: occurs with adrenal insufficiency, metabolic or respiratory acidosis

V. Nursing Diagnoses:

1. Ineffective Cardiopulmonary, Cerebral, or Renal tissue perfusion r/t reduced cardiac output caused by blood loss and hypotension. Desired Outcome:

o Patient would not develop chest pain, cardiac arrhythmias, or shortness of breath

o Skin warm and dryo Hematocrit – 32%o Stay alert and oriented to time, place, and person

o Maintain urine output of at least 30 ml hourly or 0.5 to 1 ml/kg/hr

o Regain or maintain normal GI function

o Regain normal peripheral pulses, color, and temperature.

o Systolic blood pressure 90 to 120 mm Hgo Mean arterial pressure 70 to 105 mm Hgo Cardiac index 2.5 to 4 l/min/m2o O2 sat - 95 %

2. Decreased Cardiac Output r/t diminished venous return caused by blood loss.  Desired Outcome:

o Regain normal cardiac output as evidenced by normal blood, central venous, right atrial, pulmonary artery, and pulmonary artery wedge pressure (PAWP) readings.

o Identify early signs and symptoms of decreased cardiac output (such as dizziness, syncope, cool or clammy skin, fatigue, and dyspnea), and express the importance of seeking immediate medical attention if they occur.

3. Fluid Volume Deficit that may be r/t active fluid/blood loss e.g., hemorrhage, prolonged vomiting/gastric intubation, diarrhea, burns [may be severe], profuse sweating, water deprivation, diuretic abuse, wounds, fistulas.

Desired Outcome:o Recover and maintain normal fluid volume at a functional

level as evidenced by individually adequate urine output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill.

o Recover normal hemoglobin levels, hematocrit, red blood cell and platelet counts, arterial blood gas (ABG) and electrolyte levels

o Identify causes of fluid volume deficit, and express the rationale for following a prescribed diet, taking medications, maintaining his activity level, and obtaining follow–up medical care.

VI. Nursing interventions:

A. Patient Monitoring:

Monitor the patient’s vital signs, CVP, Right atrial pressure, pulmonary artery pressure, PAWP, and CO at least hourly or as ordered. Note presence/degree of postural BP changes. Observe for temperature elevation/fever.

o Tachycardia is present along with a verifying degree of hypotension, depending on degree of FVD. CVP measurements are useful in determining degree of FV and response to replacement therapy. Fever increases metabolism and exacerbates fluid loss.

Monitor blood pressure for orthostatic changes (from patient lying supine to high-Fowler). Note the following orthostatic hypotension significance:

o Greater than 10 mm Hg drop: circulating blood volume is decreased by 20%.

o Greater than 20 to 30 mm Hg drop: circulating blood volume is decreased by 40%.

Record pulses and respiratory rates, and peripheral pulse rates every 15 minutes until stable. Monitor cardiac rhythm continuously. Note capillary refill, skin color/temperature, and note any changes. Cold, clammy skin may signal continuing peripheral vascular constriction, indicating progressive shock.

o Conditions that contribute to ECF deficit can result in inadequate organ perfusion to all areas and may cause circulatory collapse/shock.

Continuously monitor ECG to detect life-threatening dysrythmias of HR > 140 beats/min, which can adversely affect SV.

Measure the patient’s urine output hourly. Measure/estimate fluid losses from all sources e.g., gastric losses, wound drainage, diaphoresis.

o Fluid replacement needs are based on correction of current deficits and ongoing losses. Note: A diaphoretic episode requiring a full linen change may represent a fluid loss of as much as 1 L. Decreased urinary output may indicate sufficient renal perfusion/hypovolemia, or polyuria can be present, requiring more aggressive fluid replacement.

Monitor the patient’s ABG and electrolyte levels frequently as ordered.

Watch for signs of impending coagulopathy (such as petechiae, bruising, bleeding or oozing from gums or venipuncture sites).

B. Patient Assessment

Obtain patient history to ascertain the probable cause of the fluid disturbance. This can help to guide interventions. Causes may include acute trauma and bleeding, reduced fluid intake from changes in cognition, large amount of drainage post-surgery, or persistent diarrhea.

Assess or instruct pt to Weigh daily and consistently; and compare with same scale, and preferably at the same time of day with 24-hr fluid balance. Mark/measure edematous areas; e.g., abdomen, limbs

o Although weight gain and fluid intake greater than output may not accurately reflect IV volume (e.g., third-space fluid accumulation cannot be used by the body for tissue perfusion), these measurements provide useful date for comparison and facilitates accurate measurement and follows trends.

Assess skin turgor and mucous membranes for signs of dehydration. The skin in elderly patients loses its elasticity; therefore skin turgor should be assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted along the tongue.

Assess color and amount of urine. Report urine output less than 30 ml/hr for 2 consecutive hours. Concentrated urine denotes fluid deficit.

Assess LOC, mentation and for pressure ulcer development.

Evaluate client’s ability to swallow.

o Impaired gag/swallow reflexes, anorexia/nausea, oral discomfort, and changes in LOC/ cognition are among the factors that affect client’s ability to replace fluids orally.

C. Diagnostic Assessment

Review Hgb and Hct levels and note trends. Decreased RBCs can adversely affect oxygen carrying capacity.

Review lactate levels, an indicator of reduced tissue perfusion and anaerobic metabolism.

Review ABGs for hypoxemia and respiratory or metabolic acidosis.

Review BUN, creatinine, and electrolytes and more trends to evaluate renal function.

D. Patient Management

Independent:

o Ascertain client’s beverage preferences, and set up a 24-hr schedule for fluid intake. Encourage foods with high fluid content.

Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement. Note: Sense of thirst is often diminished in the older adult.

o Turn frequently, gently massage skin and protect bony prominences.

Tissues are susceptible to breakdown because of vasoconstriction and increased cellular fragility.

o Provide skin and mouth care. Bathe every other day using mild soap. Apply lotion as indicated.

Skin and mucous membranes are dry with decreased elasticity because of vasoconstriction and reduced intracellular water. Daily bathing may increase dryness.

o Provide safety precautions as indicated; e.g., use of side rails where appropriate, bed in low position, frequent observation, soft restraints (if required).

Decreased cerebral perfusion frequently results in changes in mentation /altered thought process, requiring protective measures to prevent client injury. Note: The use of restraints may increase agitation and can pose a safety risk.

o Investigate reports of sudden/sharp chest pain, dyspnea, cyanosis, increased anxiety, and restlessness.

Hemoconcentration (sludging) and increased platelet aggregation may result in systemic emboli formation.

o Monitor for sudden/marked elevation of BP, restlessness, moist cough, dyspnea, basilar crackles, and frothy sputum.

Too rapid a correction of fluid deficit may compromise the cardiopulmonary system, esp. if colloids are used in general fluid replacement (increased osmotic pressure potentiates fluid shifts).

E. Patient Teaching:

Explain all procedures and their purposes to ease the patient’s anxiety.

Discuss the risks associated with blood transfusions to the patient and his family.

Describe or teach causes of fluid losses or decreased fluid intake.

Explain or reinforce rationale and intended effect of treatment program.

Explain importance of maintaining proper nutrition and hydration.

Teach interventions to prevent future episodes of inadequate intake. Patients need to understand the importance of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits.

Inform patient or caregiver of importance of maintaining prescribed fluid intake and special diet considerations involved.

If patients are to receive IV fluids at home, instruct caregiver in managing IV equipment. Allow sufficient time for return demonstration. Responsibility for maintaining venous access sites and IV supplies may be overwhelming for caregiver. In addition, elderly caregivers may not have the cognitive ability and manual dexterity required for this therapy.

Refer to home health nurse as appropriate.

VII. Collaborative / Medical:

a. Assist with identification/treatment of underlying cause.

i. Refer to listing of predisposing/contributing factors to determine treatment needs.

b. Monitor laboratory studies as indicated; e.g., electrolytes, glucose, pH/PCO2, coagulation studies.

i. Depending on the avenue of fluid loss, differing electrolyte/metabolic imbalances may be present/require correction.

c. Use a large bore (16 to 18 gauge) cannula for intravenous lines to replace volume rapidly.

d. Administer IV solutions as indicated:

i. Isotonic solutions; e.g., 0.9% NaCl (normal saline), 5% dextrose/water;

1. Crystalloids provide prompt circulatory improvement, although the benefit may be transient (increased renal clearance)

ii. 0.45% NaCl (half-normal saline), lactated Ringer’s (LR) solution;

1. This may be used to provide both electrolytes and free water for renal excretion of metabolic wastes.

iii. Colloids; e.g., dextran, Plasmanate/albumin,hetastarch (Hespan); and crytalloids in addition to blood products as ordered.

1. Corrects plasma protein concentration deficits, thereby increasing IV osmotic pressure and facilitating return of fluid into vascular compartments.

iv. Whole blood/packed RBC transfusion, or autologous collection of blood.

1. Indicated when hypovolemia is r/t blood loss.

o Administer sodium bicarbonate if indicated.

o May be given to correct severe acidosis while correcting fluid balance.

o Provide tube feedings, including free water as appropriate.

o Enteral replacement can provide proteins and other needed elements in addition to meeting general fluid requirements when swallowing is impaired.

o Pharmacologic agents may be used to improve hemodynamic parameters if intravascular volume is replaced.

o Provide oxygen as ordered.

o Prepare the patient for surgical intervention is required.

o Institute pressure ulcer prevention strategies.

VIII. Dietary Management:

High Fiber, Low Carbohydrate, Low Fat, Low Salt Diet. Also, Iron-rich foods are recommended for hypovolemic patients.

IX. Surgical Management:

Intraosseous Infusion

Intraosseous (IO) infusion is the placement of a rigid needle through the bone cortex into the medullary cavity. This method can be used to administer blood products and fluids when a patient is in need of fluid replacement and IV access cannot be obtained. 9 The site of choice for the placement of an IO in the anterior aspect of the tibia 1 to 3 cm below the proximal tibial tuberosity. 9 This site is ideal because it is broad and flat and is easily accessible through a thin layer of skin covering the bone. 9 The site is also preferred because it is free of blood vessels, nerves, or major muscle groups. The distal medial tibia is a site that can be used in either children or adults, and is a flat, easily accessible area. Other sites that can be used are: distal femur, iliac crest, humerus, and sternum in children over age 3. 9 Nursing care for a patient with IO infusion is aimed toward immobilization of the catheter and the extremity so as not to jeopardize the site.

Surgical Intervention Aimed at Repairing the Source of Bleeding

In order for fluid volume status to stabilize and to ensure patient recovery of shock, the source of bleeding must be found and repaired early in the treatment of the patient. Early repair will significantly improve the patient's chances for a meaningful recovery.