FLUID VOLUME IMPAIRMENT

Prepared by:

LUCY MAY L. BUCAYAN, MN, RN

 TRAIN AND DISCIPLINE THE MIND
• No matter who you are, the Lord has
blessed you with intellectual faculties
capable of vast improvement. Cultivate
your talents with persevering
earnestness. Train and discipline the
mind by study, by observation, by
reflection.
• You cannot meet the mind of God unless you put
to use every power. The mental faculties will
strengthen and develop if you will go to work in
the fear of God, in humility, and with earnest
prayer. A resolute purpose will accomplish
wonders.
• Self-discipline must be practiced. An ordinary
mind, well-disciplined, will accomplish more and
higher work than will the most highly educated
mind and the greatest talents without self-
control.
• EGW, MCP, pp. 3 - 4
FLUID VOLUME
DEFICIT/HYPOVOLEMIA FLUID VOLUME
EXCESS/HYPERVOLEMIA
• FVD - ↓ in intravascular,
interstitial, and/or ICF • Fluid intake or fluid
• Dehyration - fluid intake retention (H2O & Na)
not sufficient; loss of
> fluid needs of the
H2O alone
body
• Overhydration or
fluid overload
 Disturbances in Water Balance
• Dehydration

• Hypotonic
hydration
 Types of Fluid Volume Types of Fluid
Deficit Volume Excess
a. Isotonic a. Isotonic
Dehydration/Hypovo Overhydration
lemia - ↑fluid in ECF
- H2O and electrolytes compartment and
lost from ECF expands
- Most common - No shifting b/w ECF
- ↓ blood vol. and and ICF
inadequate tissue - Circulatory overload
perfusion & interstitial
edema
 RAAS
• Dec bld vol → kidneys activate prorenin
→ secretes renin → liver angiotensin I
converted to angiotensin II by the
angiotensin converting enzyme in the
lungs → stimulates production of
aldosterone → ↑ water and Na
reabsorption of kidneys ↑ → blood
vessels constrict → ↑ BP
b. Hypertonic b. Hypertonic overhydration
dehydration - Rare; due to excessive
- H2O loss > electrolyte Na intake
loss - Fluid drawn from ICF
- ICF moves into ECF = to ECF area
cellular dehydration +
shrinkage c. Hypotonic overhydration
c. Hypotonic dehydration - Water intoxication
- Electrolyte loss > water - Excess ICF; all fluid
loss compartments expand
- ECF moves into ICF = - Electrolyte imbalance
plasma volume deficit +
cellular swelling
Types: Hypovolemia
• Mild – 2% of body weight loss

• Moderate – 5% of body weight loss

• Severe – 8% or more of body

weight loss
 Causes/Risk Factors
HYPOVOLEMIA HYPERVOLEMIA
a. Isotonic (same with
a. Isotonic
ECF; RBC doesn’t shrink
or swell) dehydration overhydration
- Inadequate intake of - IV therapy
fluids and solutes - Renal failure
- Fluid shifting b/w - Long term
compartments corticosteroid
- Excessive losses of therapy
isotonic body fluids
 Causes/Risk Factors
HYPOVOLEMIA HYPERVOLEMIA
b. Hypertonic (osmolality
exceeds ECF) dehydration
b. Hypertonic
- Excessive perspiration overhydration
- Hyperventilation - ↑Na ingestion
- Ketoacidosis - Rapid infusion of
- Prolonged fevers hypertonic saline
- Vomiting & Diarrhea (0.9% NaCl or
- Hemorrhage Ringer’s)
- Early stage renal failure
- Excessive Na
- Diabetes insipidus
bicarbonate therapy
 Causes/Risk Factors
HYPOVOLEMIA HYPERVOLEMIA
c. Hypotonic overhydration
c. Hypotonic (less - Early renal failure
osmolality) - CHF
dehydration - Syndrome of inappropriate
- Chronic illness ADH (SIADH) secretion
- Excessive fluid - Uncontrolled IV therapy
replacement - Replacement of isotonic fluid
(hypotonic) with hypotonic fluids
- - Irrigating wounds and body
Renal failure
cavities with hypotonic
- Chronic malnutrition fluids
 Clinical Manifestations
HYPOVOLEMIA HYPERVOLEMIA
• CARDIOVASCULAR • CARDIOVASCULAR
- Thready, ↑ PR - Bounding, ↑ PR
- Orthostatic (lying to - ↑ BP, pulse pressure & CVP
sitting) hypotension ↓ (> 11-12 cm of H2O)
systolic BP > 15mmHg - Distended neck & hand veins
- Dysrhythmias
- Flat neck and hand veins
in dependent positions
- ↓ peripheral pulses
- ↓venous filling
- ↓ CVP; ↓ capillary refill
- Dysrhythmias
 Clinical Manifestations
HYPOVOLEMIA HYPERVOLEMIA
• RESPIRATORY
• RESPIRATORY
- ↑RR with shallow
- ↑ RR & depth respirations
- Dyspnea - Cough, Dyspnea,
Orthopnea
- Moist Crackles (rales)
- Wheezes
 Clinical Manifestations
HYPOVOLEMIA HYPERVOLEMIA
• NEUROMUSCULAR
• NEUROMUSCULAR
- Altered mental status
(lethargy to coma) - Cerebral edema
- Anxiety & restlessnes (altered LOC)
- ↓alertness/cognition
- Headache
- ↓ in temperature unless
there is a concurrent infection - Visual disturbance
- Muscle weakness
- Skeletal muscle
- Fatigue
- Lassitude weakness
- Cramps - Paresthesias
 Clinical Manifestations
HYPOVOLEMIA HYPERVOLEMIA

• RENAL • RENAL
- ↓urine output - Kidneys compensate
(oliguria); anuria (↑ urine output);
- ↑ sp. gravity kidney damage
(decreased urine
output)
 Clinical Manifestations
HYPOVOLEMIA
• INTEGUMENTARY HYPERVOLEMIA
• INTEGUMENTARY
- Dry, pale, cool, & clammy - Puffy eyelids
- Poor turgor, tenting - Pitting edema
- ↓tongue size with (dependent areas) or
furrows anasarca
- Dry mouth & cracked lips - Pale, cool skin, taut
 Clinical Manifestations
HYPOVOLEMIA HYPERVOLEMIA
• GASTROINTESTINAL • GASTROINTESTINAL
- ↓ motility & ↓ bowel - ↑ motility
sounds
- Diarrhea
- Constipation
- ↑ body wt (5%)
- Thirst; anorexia, nausea
- Hepatomegaly
- ↓ body wt (wt loss)
- Ascites (fluid accumulates
2% - mild
in peritoneal cavity)
5% - moderate
8% severe
COLLABORATIVE CARE
 DIAGNOSTIC/LAB TESTS
HYPOVOLEMIA HYPERVOLEMIA

• ↑ BUN level • ↓ BUN level

- Plasma dilution
NV: 10 – 20 mg/dL
(3.6 – 7.2 mmol/L) - ↓ protein intake

– Dehydration or ↓
renal perfusion or
function
 DIAGNOSTIC/LAB TESTS
HYPOVOLEMIA HYPERVOLEMIA

• ↑hematocrit &
• ↓hematocrit &
hemoglobin
hemoglobin
NV: 42 – 52% (male);
35 – 47% (female) - Plasma dilution
– ↓ in plasma volume - anemia
 DIAGNOSTIC/LAB TESTS
HYPOVOLEMIA HYPERVOLEMIA
• ↑ serum osmolality
• ↓serum
NV: 280 to 300 mOsm/kg osmolality

• Urine osmolality >

450mOsm/kg
• ↓ urine specific
NV: 200 to 800 mOsm/kg gravity

• ↑specific gravity
 DIAGNOSTIC/LAB TESTS
• Serum electroltyes
- Isotonic fluid deficit (Na • Serum electrolytes –
within normal limits) WNL
- ↑ Na with H2O loss only • Hyperuricemia
(insensible loss &
diabetes insipidus)
- ↓ Na with ↑ thirst and
ADH release
- ↓K with GI & renal losses
- ↑ K with adrenal
insufficiency
 DIAGNOSTIC/LAB TESTS
• CVP . X-RAY
- Check pulmonary
congestion
 FLUID MANAGEMENT
HYPOVOLEMIA HYPERVOLEMIA
(Table 5-4, p.87 Lemone; Table • D/C Na containing
14-3 p. 272 Smeltzer) fluids
a. Oral hydration • Restrict fluids (Box
b. Isotonic electrolyte 5-3, p.91 Lemone)
solutions - expand - Substract requisite
plasma vol. fluids
- Lactated Ringer’s Followed
albumin
by

- 0.9% NaCl
 FLUID MANAGEMENT
HYPOVOLEMIA HYPERVOLEMIA
c. Hypotonic electrolyte- Divide remaining fluid
solution – if allowance:
normotensive already a. Day shift: 50% of total
e.g. 0.45% NaCl provide b. Evening shift: 25%-33%
both electrolyte and of total
water for renal c. Night shift: remainder
excretion of • Explain fluid restriction
metabolic wastes • Identify preferred fluids
and intake pattern
 FLUID MANAGEMENT
HYPOVOLEMIA HYPERVOLEMIA

• Place allowed
• Isotonic dehydration
amounts of fluid in
- isotonic solution
small glasses
• Hypertonic
• Ice chips
dehydration –
• Mouth care
hypotonic solutions
• Hypotonic • Sugarless chewing
dehydration – gum to reduce thirst
hypertonic solutions sensation
 HYPOVOLEMIA HYPERVOLEMIA
• FLUID CHALLENGE TEST • NUTRITIONAL THERAPY
- Obtain & document baseline • Refer to Box 5-5, p. 91
V/S, breath sounds, urine (Lemone)
output, & mental status • Daily consumption: 5-15 g Na
- Initial IV infusion of 100 – 300 • RDA – 500 to 2400 mg Na
mL over 5 to 15 minutes - Na restriction (250 mg/day)
- Reevaluate baseline data after -
Reduce salt in recipes by half
10- 15 minutes
- Read food labels
- Adm. additional fluid until a
specified vol. is infused or - Be cautious with salt
desired hemodynamic substitute (contains K)
parameters achieved - Use distilled water because
tap water may contain high
levels of Na
• HYPOVOLEMIA
Blood transfusion PRN

•Seasoning substitutes:
lemon, juice, onion,
garlic
 DRUG THERAPY
HYPERVOLEMIA
HYPOVOLEMIA
a. Antidiarrheal • Diuretics (Refer to
b. Antimicrobial p. 90, Lemone)
c. Antiemetic a. Thiazide diuretics
(Plasil) (Diuril) block Na
reabsorption in
d. Antipyretic
distal tubule; mild
to moderate; ↓Mg
DRUG THERAPY
HYPERVOLEMIA
b. Loop diuretics
- Lasix (furosemide ) –
block Na reabsorption
in ascending loop of
Henle; severe; ↓Mg
c. K sparing diuretic
(Aldactone) – distal
tubule
• K supplements
(hypokalemia)
 OTHER MANAGEMENT
HYPOVOLEMIA HYPERVOLEMIA
• Oxygen adm.; hemofiltration
OXYGEN ADM.
• Dialysis or Phlebotomy
• Paracentesis
• Thoracentesis
NURSING CARE PLAN
 NURSING CARE PLAN (Lemone & Black)
FVD
• HEALTH
PROMOTION/PREVENTION
• Identify clients at risk
• Minimize fluid losses
- Sports drink to replace both water
and electrolytes (exercising)
- Maintain fluid intake when ill
- 1500 mL/day esp. for elderly
- Close monitoring for abnormal
fluid losses esp. ↓LOC,
disorientation, nausea, anorexia,
and physical limitations
FVE
• HEALTH
PROMOTION/PREVENTION
- Preventive Measures: heart
& kidney problems
- Na ingestion; avoid OTC
drugs
- Monitor wt (notify if wt
gain > 5 lb in a week or less
- Monitor IVFs infusion
- Monitor S/S
 NURSING CARE PLAN
ASSESSMENT ASSESSMENT
• Health History (refer to • Health History (refer
causes/risk factors) to causes/risk
• Physical Assessment factors)
(refer to clinical
manifestations and
• Physical Assessment
diagnostic/lab tests) (refer to clinical
• Special assessment for manifestations and
Older Clients (Box 5-2, diagnostic/lab tests)
Lemone, p. 87)
 NURSING CARE PLAN
HYPOVOLEMIA HYPERVOLEMIA
1. FVD r/t abnormal • Fluid volume excess r/t
losses, insufficient CHF, excess sodium
/inadequate intake,
vomiting, diarrhea, intake, renal failure
hemorrhage Cues: Weight gain of 6 lb.
Cues: dry mucous in 24 hours; lungs with
membranes, low BP, HR
112-122, BUN 28, Na
crackles in bases
152, urine dark amber; bilaterally; 2+ edema in
Intake 200mL/Output ankles bilaterally
450mL over 24 hours
 NURSING CARE PLAN
Goal: Client will have HYPERVOLEMIA
adequate fluid
Goal: Client will have
volume within 24
normal fluid volume
hours
within 48 hours;
Moist tongue, mucous
membranes, BP ↓ weight of 1 lb. per
WNL, HR WNL, BUN day; lung sounds clear
between 8-20, Na in all fields; ankles
135-145, Urine clear without edema
yellow, balanced I/O
 NURSING CARE PLAN
• I&O – every 8 hrs or • Assess V/S, heart
even hourly sounds, CVP, vol. of
- UO should be 30-60 peripheral pulses and
mL/hr; ↓30 mL kidneys distended neck veins
attempt to conserve fluids - Hypervolemia can cause
– refer immediately HTN, bounding peripheral
• V/S, CVP, & peripheral pulses, and S3 due to vol.
pulses vol. every 4 hrs of blood flow to the
heart, ↑CVP readings,
- Hypotension, tachycardia,
and distended neck veins.
& weak peripheral pulses
indicate hypovolemia
 NURSING CARE PLAN
• Assess edemas: lower
• Assess skin turgor and extremities, back, sacral, and
tongue turgor with periorbital.
additional longitudinal - Initially, edema affects the
furrows and small dependent portions of the body,
• Assess the oral mucous lower extremities (ambulatory) or
membrane (dry mouth or sacrum (bedridden) clients. Later,
mouth breathing) periorbital edema (anasarca).
• Assess for cold & clammy - Peripheral edema: measure
skin circumference of extremity using
millimeters; elevate; use of anti-
embolism stockings
- Indicate fluid status
- Ascites: measure abd’l girth, daily
weighing
 NURSING CARE PLAN
• Assess urine UO every 8
• Weigh daily hours or hourly (severe).
- Acute loss of 0.5 kg (1 lb) Accurate I&O records.
Report UO < 30 mL/hr or
= 500 mL fluid loss ; 1kg
(+) fluid balance on 24 hr
(2.2 lb) = 1 L fluid loss total I&O
• Adm. & monitor intake - HF & inadequate renal
of oral fluids; beverage perfusion may result in
preference on schedule decrease UO and fluid
retention.
- Oral fluid preferred if the
• Rest
client can drink and
retain fluid. - Favors diuresis with ↓venous
pooling and ↑circulating
bld vol. & renal perfusion
 NURSING CARE PLAN
• Adm. IVFs with an • Weigh daily
electronic infusion - One of the most important
pump; monitor S/S of gauges in fluid balance.
fluid overload for rapid Acute weight gain or loss
infusion represents fluid gain or
- Rapid infusion → loss. Wt gain of 1 kg (2.2
hypervolemia → lb) = 1 L fluid gain
pulmonary edema & • Monitor IVF and response
cardiac failure
- May lead to circulatory
overload.
 NURSING CARE PLAN
• Monitor lab values: • Adm. oral fluids
electrolytes, serum cautiously; fluid
osmolality, BUN, restrictions; explain to SO
hematocrit, urine - All sources of fluid intake
concentration (sp. gravity including ice chips are
should be > 1.020) recorded to avoid excess
fluid intake.
- Rehydration may lead to • Oral hygiene every 2 hrs.
changes in serum
electrolytes, osmolality, - Comfort and keeps mucous
BUN, hematocrit, & sp. membranes intact ; helps
gravity relieve thirst if fluid is
restricted
• Na restricted diet; check
before bringing foods to
client (Box 5-5, p. 93,
Lemone)
- Excess sodium promotes Na
retention; Na restricted diet
is ordered to ↓ water gain
• Adm. prescribed diuretics;
monitor response
- Loop or high ceiling diuretics
can lead to rapid fluid loss
and signs of hypovolemia
and electrolyte imbalance.
 NURSING CARE PLAN
2. Ineffective Tissue 2. Risk for Impaired Skin
Perfusion r/t decreased Integrity r/t fluid
cardiac output secondary retention and edema
to hypovolemia • Frequently assess skin
• Monitor for changes in in pressure areas and
LOC and mental status. bony prominences.
- Restlessness, anxiety, - Skin breakdown can
confusion, and agitation progress rapidly when
may indicate inadequate circulation impaired.
cerebral blood flow, and
circulatory collapse.
 NURSING CARE PLAN
• Monitor serum • Reposition client every
creatinine, BUN, & 2 hrs; skin care with
cardiac enzymes. position change.
- Frequent position
- ↑ may indicate changes minimize tissue
impaired renal pressure and promotes
function, or cardiac blood flow to tissues.
perfusion due to
circulatory failure.
 NURSING CARE PLAN
• Turn at least every 2
• Provide and egg crate
hours; skin care; monitor
mattress or alternating
skin or tissue breakdown
pressure mattress, foot
- Impaired circulation to cradle, heel protectors,
peripheral tissues and other devices to
increases the risk of skin reduce pressure to tissues.
breakdown. Turn
- These devices, which
frequently to relieve distribute pressure away
pressure over bony from bony prominence,
prominences. Keep skin reduce the risk of skin
clean, dry, and moisturized breakdown.
to help maintain integrity.
 NURSING CARE PLAN
3. Risk for injury r/t 3. Risk for Impaired Gas
decreased cerebral Exchange
perfusion secondary • Auscultate lungs and
heart sounds
to hypovolemia
- Crackles and wheezes
• Safety precautions: indicate pulmonary
low bed, side rails, congestion and edema.
gradual raising from A gallop rhythm (S3)
supine to sitting; or may indicate diastolic
sitting to standing overloading of the
ventricles secondary to
position. fluid volume excess
 NURSING CARE PLAN
- Using safety precautions • Semi- Fowler’s to
and allowing BP to
adjust to position
Fowler’s position
changes reduce risk for - Improves lung
injury expansion by
• Teach to reduce
decreasing the
orthostatic hypotension
a. Move from one position
pressure of
to another in stages abdominal
contents on the
diaphragm.
 NURSING CARE PLAN
b. Avoid prolonged • O2 Sat (< 92% - 95%) & ABG
standing. (PaO2 <80mmHg)
monitoring
c. Rest in recliner - Edema of interstitial lung
rather than in bed tissues can interfere with gas
exchange and delivery to
during daytime. body tissues. Supplemental
O2 promotes gas exchange
d. Use assistive across the alveolar-capillary
devices when membrane, improving tissue
oxygenation.
picking up objects
 NURSING CARE PLAN
HYPERVOLEMIA
- Reduce orthostatic
4. Activity intolerance
hypotension;
r/t FVE, fatigue, and
prolonged rest ↑
muscle weakness
weakness and ↓
venous tone; - Promote rest
prolonged standing – Energy
blood pools ↓venous conservation;
return and CO favors diuresis
GERONTOLOGIC CONSIDERATIONS
HYPOVOLEMIA HYPERVOLEMIA
• Monitor I & O
• Monitor daily weight • Monitor I & O
• Monitor side effects and • Monitor daily weight
interaction of
• Monitor side effects
medications
• Prompt reporting &
and interaction of
management of medications
disturbances • Monitor IVF’s
• Monitor skin turgor • Monitor for edema
(forehead or sternum)
GERONTOLOGIC CONSIDERATIONS
HYPOVOLEMIA HYPERVOLEMIA
• Check for orthostatic
hypotension • Raise head of
• Check for swelling of bed
veins in hands and feet
• Assess to determine • Provide skin care
fluid and food needs
• Manage urinary
incontinence
• Direct pressure to
bleeding
 DISCHARGE PLAN
HYPOVOLEMIA HYPERVOLEMIA
• Medication • Medication
a. Antidiarrheal a. Loop diuretics
b. Antimicrobial b. Thiazide and thiazide-like
c. Antiemetic (Plasil) c. Potassium-sparing
d. Antipyretic • Exercise/Activity
• Exercise/Activity - Rest
- Rest • Treatment
• Treatment
- Oral rehydration
(oresol/oretabs)
 DISCHARGE PLAN
• Health • Health Education/Teaching
Education/Teaching - Report S/S of FVE
- Monitor S/S of fluid - Route, dosage, intended
imbalance and adverse effects, what
to report
- Monitor fluid balance
- Weight monitoring
- Avoid exercising during - Prevent or decrease
extreme heat edema:
- ↑fluid intake during hot a. Change position frequently
weather
 - Avoid restrictive clothing
- Vomiting: take small - Avoid crossing legs
frequent amounts of - Wear support stockings
or hose
ice chips or clear
- Elevate feet and legs
liquids (weak tea,
when sitting
flat cola, or ginger • Protection for
ale) edematous skin
- Reduce intake of - Don’t walk barefoot
coffee, tea, alcohol - Buy well-fitting shoes;
shop in PM
• OPD Visit
• Use 2 or 3 pillows; or use
- follow-up visit as recliner when sleeping to
scheduled relieve orthopnea
• Diet • Diet
- Fluid intake (1500 mL or - Low Na diet
more) - Read food labels
- Diarrhea (fruit juices or - Fluid restrictions per
bouillon) rather than ↑ day
amount of tap water Spiritual Care
- Alternate fluid sources:
gelatin, frozen juices,
ice cream
• Spiritual Care