CHAPTER 57 - FLUID IMBALANCES Flashcards
CHAPTER 57
Fluid Imbalances
Body fluids are distributed between
intracellular fluid (ICF) and extracellular fluid (ECF) compartments.
ICF lies within
MAKES UP HOW MUCH OF TOTAL BODY FLUIDS IN ADULTS
body cells and constitutes two-thirds of the total body fluids in adults.
ECF is comprised of
intravascular, interstitial, lymph, transcellular fluids
PLASMA
intravascular FLUID
INTERSTITIAL FLUID
fluid that surrounds the cells
transcellular fluids
cerebrospinal,
pericardial,
pancreatic,
pleural,
intraocular,
biliary,
peritoneal,
synovial fluids
Fluid can move between
compartments (through selectively permeable membranes) by a variety of methods in order to maintain homeostasis.
METHODS FLUID CAN MOVE BETWEEN COMPARTMENTS
(diffusion, active transport, filtration, osmosis)
Fluid imbalances that the nurse should be familiar with are fluid volume deficit and fluid volume excess.
fluid volume deficit and fluid volume excess.
FLUID VOLUME DEFITICT (FVD)
or isotonic dehydration, is a lack of both water and electrolytes, causing a decrease in circulating blood volume. This is also called fluid volume deficit (FVD).
AKA - Hypovolemia
FLUID VOLUME EXCESS (FVE)
Excess fluid volume, fluid overload, and fluid or water retention are all phrases to describe the medical term, hypervolemia. Hypervolemia iswhen the body has too much fluid. Fluid overload occurs when the body can’t get rid of fluid or holds onto it (retention) usually caused by excess sodium
Dehydration
is a lack of fluid in the body, from insufficient intake or excessive loss.
◯
Actual dehydration
is a lack of fluid in the body;
relative dehydration
involves a shift of water from the plasma (blood) to the interstitial space.
◯
Hypovolemia, AKA
or isotonic dehydration, is a lack of both water and electrolytes, causing a decrease in circulating blood volume. This is also called fluid volume deficit (FVD).
● Compensatory mechanisms include
sympathetic nervous system responses
sympathetic nervous system responses INCLUDE
of increased thirst, antidiuretic hormone (ADH) release, and aldosterone release.
● Rapid or severe dehydration can induce
● Rapid or severe dehydration can induce seizures.
● FVD can lead to
hypovolemic shock.
● Older adults have an increased risk for dehydration due to multiple physiological factors including
a decrease in total body mass, which includes total body water content
a decrease in the ability to detect thirst.
CAUSES OF ISOTONIC FVD (HYPOVOLEMIA)
Excessive gastrointestinal (GI) loss:
● Excessive skin loss:
● Excessive renal system losses:
● Third spacing:
● Hemorrhage
● Altered intake:
Excessive gastrointestinal (GI) loss:
vomiting, nasogastric suctioning, diarrhea
● Excessive skin loss:
diaphoresis without water and sodium replacement
● Excessive renal system losses:
diuretic therapy, kidney disease, adrenal insufficiency
● Third spacing:
burns
● Hemorrhage or
plasma loss
● Altered intake:
anorexia, nausea, impaired swallowing, confusion, nothing by mouth (NPO) (decreased intake of water and sodium)
NPO
(decreased intake of water and sodium)
CAUSES OF DEHYDRATION
Hyperventilation / excessive perspiration w/out water replacement
● Prolonged fever
● Diabetic ketoacidosis
● Insufficient water intake
● Diabetes insipidus
● Osmotic diuresis
● Excessive intake of salt, salt tablets, or hypertonic IV fluids
POSSIBLE REASONS FOR Insufficient water intake
(enteral feeding without water administration, decreased thirst sensation, aphasia)
DEHYDRATION EXPECTED FINDINGS
VITAL SIGNS: ALTERATIONS
NEUROMUSCULOSKELETAL ALTERATIONS
GI ALTERATIONS
RENAL ALTERATIONS
OTHER ALTERATIONS
VITAL SIGNS: - DEHYDRATION
Hypothermia (hypovolemia) or
hyperthermia (dehydration),
tachycardia,
thready pulse,
hypotension,
orthostatic hypotension,
decreased central venous pressure,
tachypnea (increased respirations),
hypoxia
NEUROMUSCULOSKELETAL - DEHYDRATION
Dizziness,
syncope,
confusion,
weakness,
fatigue;
seizures (rapid/severe dehydration)
GI - DEHYDRATION
Thirst,
dry mucous membranes,
dry furrowed tongue,
nausea,
vomiting,
anorexia,
acute weight loss
RENAL - DEHYDRATION
Oliguria (decreased production of urine)
OTHER FINDINGS - DEHYDRATION
Diminished capillary refill,
cool clammy skin,
diaphoresis,
sunken eyeballs,
flattened neck veins,
absence of tears,
decreased skin turgor
Assessment of skin turgor in the older adult might not
provide reliable findings due to a natural loss of skin elasticity.
Hct FINDINGS - DEHYDRATION
Increased in both hypovolemia and dehydration unless the fluid volume deficit is due to hemorrhage
Blood osmolarity: - DEHYDRATION
Dehydration: Increased hemoconcentration osmolarity (greater than 295 mOsm/kg)
Urine specific gravity: - DEHYDRATION
Dehydration: Increased concentration (urine specific gravity greater than 1.030)
Blood sodium: - DEHYDRATION
Dehydration: Increased hemoconcentration (greater than 145 mEq/L)
BUN: - DEHYDRATION
Increased (greater 25 mg/dL) due to hemoconcentration
Dehydration:
Increased protein, electrolytes, glucose
NURSING ACTIONS FOR DEHYDRATION
Monitor respiratory rate, effort, / oxygen saturation (SaO2).
● Check urinalysis, CBC, / electrolytes.
● Administer supplemental oxygen as prescribed.
● Measure weight daily - same time of day / same scale.
● Observe - nausea / vomiting.
● Assess postural blood pressure / pulse. (Check for hypotension / orthostatic hypotension.)
● Check neurologic status - determine level of consciousness.
● Assess heart rhythm.
● Initiate / maintain IV access.
● Provide oral / IV rehydration therapy as prescribed.
● Monitor I&O. Encourage fluids as tolerated. Alert provider IF urine output < 30 mL/hr.
● Monitor level of consciousness / ensure client safety.
● Observe level of gait stability.
● Encourage client - use call light / ask for assistance.
● Encourage client - change positions slowly (rolling from side to side or standing up).
Overhydration
is too much fluid in the body, from excessive intake, or ineffective removal from the body.
◯ Fluid overload
is an excess of fluid or water (w/ water intoxication).
FLUID OVERLA
This includes
EXCESS OF FLUID OR WATER (W/ WATER INTOXICATION) INCLUDES
hemodilution,
hemodilution,
which makes the amount of blood components (blood cells, electrolytes) seem lower.
◯ Hypervolemia, or
fluid volume excess, involves and excess of water and electrolytes, so that the two are still in the right proportions.
◯ Hypervolemia, EXAMPLE
For example, excessive sodium intake causes the body to retain water, so that there is too much of both.
Severe FVE can lead to
pulmonary edema and heart failure.
● Compensatory mechanisms include an
increased release of natriuretic peptides,
increased release of natriuretic peptides, CAN CAUSE
increased excretion of sodium and water by the kidneys, usually accompanied by a decreased release of aldosterone.
CAUSES OF HYPERVOLEMIA - AKA -
FLUID VOLUME OVERLOAD (FVE)
Chronic stimulus to kidney to conserve sodium / water
● Altered kidney function W/ reduced excretion of sodium / water
● Interstitial to plasma fluid shifts (hypertonic fluids, burns)
● Age‑related changes in cardiovascular / kidney function
● Excessive sodium intake from IV fluids, diet, or medications (sodium bicarbonate antacids, hypertonic enema solutions)
HEMODILUTION - FORM OF
OVERHYDRATION / FLUID OVERLOAD
WHAT CONDITIONS CAN CAUSE CHRONIC STIMULUS TO KIDNEYS TO CONSERVE SODIUM AND WATER
heart failure, cirrhosis, increased glucocorticosteroids
(kidney failure)
Altered kidney function W/ reduced excretion of sodium / water
(hypertonic fluids, burns)
Interstitial to plasma fluid shifts
Excessive sodium intake CAN HAPPEN FROM
IV fluids, diet, or medications (
MEDICATIONS THAT CAN CAUSE EXCESSIVE SODIUM INTAKE
sodium bicarbonate antacids, hypertonic enema solutions)
CAUSES OF OVERHYDRATION
Water replacement w/out electrolyte replacement,
excessive water intake (forced or psychogenic polydipsia)
● (SIADH),
● Excessive administration of IV D5W;
psychogenic polydipsia
??
SIADH
Syndrome of inappropriate antidiuretic hormone
the excess secretion of ADH
Excessive administration of IV D5W; CAN COME FROM
use of hypotonic solutions for irrigations, enemas
VITAL SIGNS: - OVERHYDRATION
Tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure
NEUROMUSCULOSKELETAL: - OVERHYDRATION
Confusion, muscle weakness, altered level of consciousness, paresthesias, visual changes; seizures (if severe, sudden hyponatremia/water excess).
GI: - OVERHYDRATION
Increased motility, ascites
RESPIRATORY: - OVERHYDRATION
Dyspnea, orthopnea, crackles
OTHER FINDINGS: - OVERHYDRATION
Pitting edema, distended neck veins, we
Hct: ● Hypervolemia:
Decreased Hct;
Hct: ● Overhydration
Decreased Hct = hemodilution
Blood osmolarity: Overhydration:
Osmolarity less than 280 mOsm/kg
Blood sodium: Overhydration:
Sodium decreased
BUN: Hypervolemia:
Decreased
Arterial blood gases: overhydration
Respiratory alkalosis: Decreased PaCO2 (less than 35 mm Hg), increased pH (greater than 7.45)
Respiratory alkalosis:
Decreased PaCO2 (less than 35 mm Hg), increased pH (greater than 7.45) THIS HAPPENS IN OVERHYDRATION; WHAT IS THE CHANGE THAT HAPPENS IN DEHYDRATION
Urine specific gravity: overhydration
Less than 1.010 (if not due to SIADH)
Other electrolytes: Overhydration:
decreased
Chest x‑rays can indicate
pulmonary congestion.
A client who has excess fluid and water (fluid volume excess) will require
sodium restriction.
FVE and overhydration usually require
fluid restriction.
NURSING CARE - OVERHYDRATION
Observe respiratory rate, symmetry, / effort.
● Auscultate breath sounds - all lung fields. Lung sounds can be diminished w/ crackles.
● Monitor - SOB / dyspnea.
● Check ABGs, SaO2, CBC, / chest x‑ray results.
● semi‑Fowler’s position.
● Measure client’s weight daily - same time / same scale.
● Monitor / document edema (pretibial, sacral, periorbital).
● Monitor I&O.
● Implement prescribed restrictions - fluid / sodium intake.
◯ Provide fluids in small glass - promote perception of full glass of fluid.
◯ Set 1‑ to 2‑hr short‑term goals for fluid restriction - promote client control / understanding.
● Administer supplemental oxygen as needed.
Reduce IV flow rates.
● Administer diuretics (osmotic, loop) as prescribed.
● Monitor / document circulation to extremities.
● Reposition client at least every 2 hr.
● Support arms / legs to decrease dependent edema.
EXAMPLES OF DIURETICS
OSMOTICS AND LOOPS
LOCATIONS OF EDEMA OF OVERHYDRATION
pretibial, sacral, periorbital)
A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply.)
A. Distended neck veins
B. Hyperthermia
C. Tachycardia
D. Syncope
E. Decreased skin turgor
A. Distended neck veins is an expected finding of hypervolemia.
B. Hypothermia is an expected finding of hypovolemia.
C. CORRECT: Tachycardia is an expected finding of hypovolemia.
D. CORRECT: Syncope is an expected finding of hypovolemia.
E. CORRECT: Decreased skin turgor is an expected finding of hypovolemia.
A nurse on a medical‑surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia?
A. A client who has nasogastric suctioning
B. A client who has chronic constipation
C. A client who has syndrome of inappropriate antidiuretic hormone
D. A client who took an toxic dose of sodium bicarbonate antacids
A. CORRECT: Identify that a client who has nasogastric suctioning is at risk for hypovolemia due to excessive gastrointestinal losses.
B. Diarrhea, rather than constipation, places the client at risk for hypovolemia due to excessive gastrointestinal losses.
C. Syndrome of inappropriate antidiuretic hormone places the client at risk for hypervolemia due to overhydration.
D. A toxic dose of sodium bicarbonate antacids places the client at risk for hypervolemia due to excessive sodium intake.
A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? (Select all that apply.)
A. Hct 55%
B. Blood osmolarity 260 mOsm/kg
C. Blood sodium 150 mEq/L
D. Urine specific gravity 1.035
E. Blood creatinine 0.6 mg/dL
A. CORRECT: This Hct is greater than the expected reference range of 42‑52% for males and 37‑47% for females and is an indication of dehydration due to hemoconcentration.
B. This blood osmolarity is within the expected reference range of 285‑295 mOsm/kg. A blood osmolarity greater than 295 mOsm/kg is an indication of dehydration.
C. CORRECT: This blood sodium level is greater than the expected reference range of 136‑145 mEq/L and is an indication of dehydration due to hemoconcentration.
D. CORRECT: This urine specific gravity is greater than the expected reference range of 1.005‑1.030. An increased urine specific gravity is an indication of dehydration.
E. This blood creatinine is within the expected reference range of 0.6 to 1.3 mg/dL. An elevated blood creatinine level is an indication of dehydration.
A nurse on a medical‑surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction?
A. A client who has a new diagnosis of adrenal insufficiency
B. A client who has heart failure
C. A client who is receiving treatment for diabetic ketoacidosis
D. A client who has abdominal ascites
A. A client who has adrenal insufficiency is at risk for isotonic fluid volume deficit (hypovolemia) because of a decrease in aldosterone secretion and an increase in sodium and water excretion .
B. CORRECT: Anticipate a client who has heart failure to require fluid and sodium restriction to reduce the workload on the heart.
C. A client who has diabetic ketoacidosis is at risk for dehydration because hyperglycemia can cause osmotic dieresis which leads to dehydration and electrolyte loss.
D. A client who has ascites is at risk for hypovolemia because of a fluid shift from the intravascular space to the abdomen.
A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include?
A. Administer antihypertensive on schedule.
B. Check the client’s weight each morning.
C. Notify the provider of a urine output greater than 30 mL/hr.
D. Encourage independent ambulation four times a day.
A. Hypotension is a manifestation of dehydration therefore the administration of antihypertensive medication would further lower the client’s blood pressure and increase the risk for injury.
B. CORRECT: Include obtaining the client’s weight each day in the plan of care. To ensure accuracy the client’s weight should be obtained at the same time each day using the same scale. By determining the client’s weight gain or loss each day the nurse can evaluate the client’s response to treatment.
C. A urine output greater than 30 mL/hr is an expected finding and is an indicator of adequate fluid balance. Plan to monitor the client’s urine output and notify the provider if it is less than 30 mL/hr.
D. The client who has dehydration is at risk for falls due to orthostatic hypotension, possible decrease in level of consciousness, and possible gait instability. Encourage the client to use the call light and ask for assistance when getting out of bed or ambulating.
Describe the diagnosis of fluid volume excess.
Fluid volume excess (FVE) is the isotonic retention of water and sodium in high proportions.
Identify two complications that can result from this disorder. FVE
● FVE is often referred to as hypervolemia because of the resulting increased blood volume.
● Severe FVE can lead to pulmonary edema and heart failure.
Identify at least five expected assessment findings and three expected laboratory findings. FVE
● Vital signs: Tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure
● Neuromusculoskeletal: Confusion, muscle weakness
● GI: Weight gain, ascites
● Respiratory: Dyspnea, orthopnea, crackles
● Other findings: Edema, distended neck veins
Decreased Hct
● Blood sodium within the expected reference range
● Decreased BUN
● Respiratory alkalosis: decreased PaCO2 (less than 35 mm Hg), increased pH (greater than 7.45)
● Urine specific gravity less than 1.010
NURSING CARE: Identify at least five interventions the nurse should include in the plan of care. FVE
Observe respiratory rate, symmetry, / effort.
● Auscultate breath sounds - all lung fields. Lung sounds can be diminished w/ crackles.
● Monitor - SOB / dyspnea.
● Check ABGs, SaO2, CBC, / chest x‑ray results.
● semi‑Fowler’s position.
● Measure client’s weight daily - same time / same scale.
● Monitor / document edema (pretibial, sacral, periorbital).
● Monitor I&O.
● Implement prescribed restrictions - fluid / sodium intake.
◯ Provide fluids in small glass - promote perception of full glass of fluid.
◯ Set 1‑ to 2‑hr short‑term goals for fluid restriction - promote client control / understanding.
● Administer supplemental oxygen as needed.
Reduce IV flow rates.
● Administer diuretics (osmotic, loop) as prescribed.
● Monitor / document circulation to extremities.
● Reposition client at least every 2 hr.
● Support arms / legs to decrease dependent edema.
