FLUID VOLUME DEFICIT FLUID VOLUME EXCESS THIRD SPACE FLUID SHIFT

FLUID VOLUME DEFICIT

Three Basic TypesIsotonic DehydrationHypertonic Dehydration Hypotonic Dehydration

Isotonic Dehydration

- Most common- Loss of isotonic fluids from the ECF, plasma and interstitial spaces.- Loss of F/E at the same proportion- Results to inadequate tissue perfusion

EtiologyPoor intake of fluids and solutes, heavy losses of isotonic body fluids.HemorrhageVomitingDiarrheaProfuse salivation,Fistulas, abscesses Ileostomy, Cecostomy Frequent enemas Burns, Prolonged NPODiuretic therapyGIT suction.

HYPERTONIC DEHYDRATION

Water loss from the ECT> electrolyte loss osmolarity of plasma.Water move from ECT and interstitial fluid spaces to the plasma cellular dehydration and CELL shrinkage.

Etiology

Excessive sweating Hyperventilation, Ketoacidosis Prolonged fevers Diarrhea, Early stage renal failure DI, RF Watery diarrhea, Excessive Hypertonic fluid replacementExcessive NaHCO3 , tube feeding Dysphagia Impaired thirst Unconsciousness FeverImpaired motor Function Systemic infection Addisons dse

3. HYPOTONIC DEHYDRATION least common typeresults from fluid shifts between spaces, causing decrease in plasma volume.

loss of Na & K from ECF blood & interstitial fluid osmolaritylowers the osmotic pressureMovement of water from plasma and interstitial spaces plasma volume deficit and swelling of cells neurologic problems.EtiologyChronic illness: CRF w/ Na+ wasting, excessive ingestion/administration of hypotonic fluids, chronic/severe malnutrition

CLINICAL MANIFESTATIONS FVD Cellular dehydration

- Thirst- Dry mucous membranes of mouth and eyes- Cracked lips and tongue furrows, difficult swallowing- Tenting of the skin (decreased turgor) - Soft sunken eyes- Decrease in systolic BP, weak pulse, HR & PR - Flat jugular veins in supine position- Prolonged peripheral venous filling time of more than 5 seconds.- temperature (vessel constriction) - Muscle weakness (Na K imbalance)- Changes in I & O.- Weight loss- Hard stool (compensatory reabsorption of fluid from the colon)Cerebral signs (intracellular compartmental shifting)Early signs: apprehension, restlessness, headacheSevere: hallucinations, confusion, coma.

ASSESSMENTHistoryAsk about:Abnormal or excessive fluid losses: sweating, diarrhea, bleeding, vomiting, urination, salivation, and wound drainage.Chronic illness, recent acute illness, recent surgery, drug regimens.Urine output, frequency and amount of voiding, usual fluid intakeIntake during the previous 24 hoursStrenuous physical activity

Diagnostic Findings

Serum osmolarity Plasma sodium BUN Plasma glucose Hct Hgb (hemoconcentration, hypotonic dehydration w/ plasma volume deficits) USG > CVP

Nursing DxDeficient fluid volume r/t excessive fluid loss (vomiting, diarrhea, hemorrhage, or third-space fluid loss such as ascites or burns) or insufficient fluid intake.Impaired oral mucous membrane R/T lack of oral intake/ inadequate oral secretions.Decreased cardiac output r/t decreased plasma volume.Risk for injury related to orthostatic hypotension.

Expected Outcomes:BP and PR WNL24-hour fluid intake & fluid output balance.USG < 1.030Good skin turgor (-)tenting

MANAGEMENTGoal: restore normal fluid volume, replace ongoing losses, correct underlying problem (vomiting or diarrhea)a. MedicalOral rehydration OFI, ORS Avoid chocolate, coffee cola drinks, sugar

1. IV REHYDRATIONAcute or severe lossesCalculated on the clients weight & presence of any other comorbidities (cardiac, renal, liver or pulmonary disorders)Hypotensive clients:

- Isotonic IVF to expand plasma volume (LR, 0.9 NaCL)Normotensive clients:

- Hypotonic electrolyte solutions (eg, 0.45% NaCl) - provide both electrolytes and water for renal excretion of wastes.- Na solution are infused at a rate of 0.5 to 1 mEq/L/hr to avoid cerebral edema.

Fluid Challenge

determines whether depressed renal function is d/t renal blood flow 2 to FVD (prerenal azotemia) or to acute tubular necrosis100 - 200ml of NSS for 15 min.Goal: provide fluids rapidly enough to attain adequate tissue perfusion w/o compromising the CV system.

2. Drug therapyAntiemeticsAntidiarrheal drugs Antibiotics infectious diarrheaAntipyretic

3. Monitoring for Complications of FVD RestorationIVF adm. is based on the clients overall conditionSevere ECFVD with heart, pulmonary, liver or kidney disease = at risk of heart failure Accurate and frequent assessment of I & O ,WT, V/S, CVP, LOC, Breath sounds

Nursing Management Restore oral fluid intakeSmall amounts of fluid of choice hourly to older, confused, or debilitated clientsWet lips and mouthGive antiemetics Clear liquids - full liquid - solid foods.Position properly to avoid aspiration.Give oral care Avoid alcohol-based mouthwash.

Restore fluids by intravenous routeAdm. fluids cautiously for clients w/ ECFVD.Use IV pump to regulate IV infusion Monitor IV solutions, sites, and client outcomes hourly. (to prevent overflow diuresis, hypernatrmia, pulmonary overload)

Reduce the risk of Deficient Fluid VolumeTube feeding : recommend 1ml dil: 1 kcal of feeding formula.

(eg. 380 kcal in 240 ml of formula add 140 ml of water for a total of 380 ml of fluid).Measure I & O accurately.

Monitor USG Monitor skin & tongue turgor- The skin turgor is not a valid test in elderly people due to loss of skin elasticity.

Control the underlying problemsExamine the clients prescription and nonprescription medication list.Avoid fatty or fried foods to decrease diarrhea and enhances digestion

Monitor LOC, V/S, breath sounds, skin color Be alert for signs of overloadMental function is affected due to cerebral perfusion- Rapid, weak pulse indicates FVD - Postural hypotension a drop in systolic BP exceeding 15 mm Hg from lying to sitting position

FLUID VOLUME EXCESS

FLUID VOLUME EXCESS/ HYPERVOLEMIAECFVE or overhydration.Excess fluids can be found

- vascular system (hypervolemia)- interstitial spaces (third-spacing).

Three Typesa. Isotonic overhydrationb. Hypotonic overhydrationc. Hypertonic overhydration

Third Space Fluid Shift

Isotonic overhydration: - expansion of ECF space only- in water volume & solute concentration (esp Na) in proportion equal to its normal isoosmolar state- No ICF stateb. Hypotonic overhydration- expansion of both the ECF and ICF compartments- Water intoxication- in water volume w/o in Na concentration- Osmotic fluid shifts from ECF to ICF (Cell swelling)c. Hypertonic overhydration Osmotic fluid shift from ICF to ECF in Na concentration w/ water volume remaining normal

THIRD SPACE FLUID SHIFT shift into potential spaces : pleural, peritoneal, pericardial, joint cavities, bowel or interstitial spaceFluids trapped in body space ; unavailable for useSymptoms & consequences Ascites peritoneal cavityPleural effusion Pericardial effusion life threatening Pedal EdemaAnasarca Pulmonary edema fluid in interstitial spaces in the lung; life threatening

ETIOLOGY (FVE)Compromised regulatory mechanism

a. Kidneys malfunction = inability to excrete excesses b. Cardiac failure = accumulation of fluid : lungs & dependent parts c. Liver cirrhosis = failure to metabolize 3 basic food groups (CHO, Fats, CHON)Excessive administration of Na containing fluids in a pt. w/ impaired regulatory mechanismCorticosteroid therapyExcessive ingestion of table or other Na saltsHypothyroidismLymphatic or venous obstructionHyperaldosteronism= Na reabsorption by the kidneys & GIT SIADH: dilutional hyponatremia

PATHO FVE MS WORD

GENERAL CLINICAL MANIFESTATIONS

A.Respiratory (Pul. edema/Pleural Effusion)RR, shallow respirations, dyspnea, Coughing, dyspnea & crackles Pallor, cyanosis, decreased tissue perfusion = impaired O2 and CO2 exchangePleural effusion = fluids shifting in pleural spaces d/t hydrostatic pressure.

B.CV Systemic venous engorgement d/t delayed emptying and filling of RVJugular vein distention/neck vein engorgementperipheral vein filling (CRT) >5 secBounding or irregular pulse,PR, CVP, BP PULSE pressure

C. Accumulation of fluid in interstitial spaces Edema: feet & sacrum Anorexia & bloating (stomach) = d/t shifting of fluid

in visceral tissues Rapid wt gain (2 lbs/day or 1L/day of fluid). Anasarca

D. IntegumentaryPitting edema in dependent areasNonpitting edema in areas of loose skin folds stasis, dermatitis, ulcersWeeping edemaSkin pale and cool to touchE. Cerebral dysfunction d/t intracellular fluid shifting Confusion headache lethargy seizures coma

DIAGNOSTIC FINDINGSPlasma < 275mOsm/kgS. Na< 135mEq/L BUN < 8mg/dl Hct < 45% Azotemia - nitrogen levels in the blood

- urea & creatinine not excreted USG

NURSING DIAGNOSIS Excess fluid volume r/t : heart, renal, liver failureDecreased cardiac output r/t heart failureRisk for altered skin integrity, injuryAltered comfortImpaired gas exchange

MANAGEMENT (FVE)Medical Restrict Na & fluid intakePromote urine output

a. Thiazide diuretics : e.g. Hydrochorothiazideb. Loop diuretics: Furosemidec. Potassium sparing diuretics: SpironolactoneACE inhibitors and beta blockers = improves cardiac functionHemodialysis or peritoneal dialysis Diet therapy: CHON diet

NURSING INTERVENTIONMonitor I & O strictly.Collaborate w/ the dietician in planning Na & fluid restrictionsGive cold fluids :thirstRegulate IV accurately.Use isotonic saline for bladder or NGT irrigationsSuggest alternatives for seasoning: lemon, garlic, pepperAvoid long periods of standing Elevate legs when sitting/lyingBed rest to promote diuresis ( pts w/ HF)

Elevate head at 30-45 venous returncardiac workload allows improved diaphragmatic excursionpromotes jugular venous drainage w/c improves cerebral perfusionAdminister O2 as prescribed to keep O2 saturation greater than 90%Monitor for plasma electrolytesTurn the client frequently Control moisture and shearLubricate the skin of the legs

AssignmentElectrolytesHyponatremiaHypernatremiaHypokalemiaHyperkalemia