Fluid Assessment Flashcards
What is fluid assessment?
The evaluation of hydration state or water homeostasis.
Why is fluid assessment important?
Injury/illness can change fluid balance. This affects fluid balance of the ICF and ECF compartments of the body, the concentration of electrolytes within fluid compartments and the body’s hydrogen ion concentration (pH).
What is hypovolemia?
Not enough fluid in the vessels.
What is hypervolemia?
Too much fluid in the body or too much volume in the vessels.
What are electrolytes?
Minerals/substances that have a charged particle when dissolved in water.
What is fluid balance?
A term used to describe the balance of intake and output of fluids in the body, to allow metabolic processes to function properly.
The adult human body needs a fluid intake of 2-3 litres which allow it to keep a balance of the nutrients, oxygen and water, which are necessary to preserve a stable healthy internal environment.
This process is known as what?
Homeostasis in relation to fluid balance.
Fluid volume deficit (FVD) is also known by what other names?
Hypovolemia, dehydration or fluid depletion.
Fluid volume excess (FVE) is also known by what other names?
Hypervolemia, overhydration or fluid overload (FVO).
Break down the word ‘hypovolemia’.
Hypo = Low
+
Volemia = Volume
+
Emia = Blood
Break down the word ‘hypervolemia’.
Hyper = High
+
Volemia = Volume
Severe cases of hypovolemia are called?
Hypovolemic shock.
What does metabolism mean?
The chemical reactions in the body’s cells that change food into energy.
Why is metabolism important?
Our bodies need this energy to do everything from moving to thinking to growing.
How do we maintain homeostasis in relation to fluid balance?
To maintain homeostasis, the adult human body needs a fluid intake of 2-3 litres.
How do you know how much fluid someone should be taking in?
Use formula –> 30ml x per KG body
_____ and ______ should be roughly equal to maintain neutral fluid balance.
Intake and output should be roughly equal to maintain neutral fluid balance.
What is the amount of body fluid lost daily that is not easily measured called?
Insensible losses.
What are the two primary body fluid compartments?
Intracellular fluid (ICF) and extracellular fluid (ECF).
We know that there is water inside the cells and outside the cells. What separates each compartment?
A cell membrane.
How to remember ICF?
Intracellular fluid think ‘INSIDE’ the cell.
What compartment do the plasma and interstitial fluid belong to?
The ECF.
What separates the two compartments in the ECF?
A capillary membrane.
What is this vessel called?
A capillary.
What is a membrane?
A thin layer of cells that forms the outer boundary of a living cell or of an internal cell compartment.
What is homeostasis?
Homeostasis is about maintaining a stable internal condition. It’s about balance. Think fluid ‘BALANCE’. Meaning body is in balance.
What is body fluid?
Refers to the mixture of water, electrolytes, and other substances found in the fluids within and between the cells of the body.
How are body fluids distributed?
Through their compartments.
What is the nursing goal of fluid electrolyte and acid-base imbalance?
To re-establish and maintain a normal balance.
What are the 3 ways we assess fluid balance?
- Fluid balance charts
- Physical assessment of fluid balance
- Monitoring of blood results.
What is the formula on how much fluid you should be drinking?
30ml x per KG body weight
Thinking logically, if someone is drinking water/fluid, will they be voiding too?
Yes, as frequently as they should be if their fluid is in balance.
What is a sign that there may be an imbalance? Think logically and simply.
Someone not passing urine as much as they should OR if they’re drinking as normally or more then normally and still not outputting as much.
What is a simple thing you can do first if someone is drinking normally or more then normally and still not outputting as much?
Check if they have a blocked catheter.
Name the components of a fluid balance chart?
- Pt details - Name, DOB, MRN, address, MO
- Date and time (written in 24 hours).
- Intake (on left side): Fluid taken via oral, IV or tube
- Output (on right side): Urine, emesis, liquid stool, drains, tubes, suctions.
- Description of what the intake or output is.
- Amount - written in ml.
- Progression total.
What is I & O’s?
Input & outake.
How do you calculate progression total?
The new total always includes adding the previous one.
What is a positive (+) fluid balance?
Fluid volume excess (FVE) = Intake is higher than output.
What is a negative (–) fluid balance?
Fluid volume deficit (FVD) = Output is higher than intake.
What is a neutral/even balance?
Intake = output (equal intake and output).
How do you calculate fluid balance?
Intake – output
Name 6 ways you could physically assess fluid status?
- Vital signs
- Facial/oral assessment
- Weight
- Urine output
- Skin
- Thirst
Hypovolemia is caused by..?
Hypovolemia = Not enough fluid in the vessels.
Caused by a loss of fluid anywhere.
Hypovolemia can be caused by conditions that cause ______?
Polyuria - Excessive urination.
What are some signs and symptoms of FVD?
FVD = Think low and little body.
Weight loss = Water loss
Cardiovascular = Low BP, orthostatic hypotension, weak and thready pulses, tachycardia
Integumentary = Sunken eyes, poor skin turgor, dry mucous membranes, increased temp
Neuromuscular = Weakness
Renal & urinary = Increased urine output initially & decreased urine output at the end
Respiratory = Rapid and deep respirations
Gastrointestinal = Constipation.
What are some abnormal lab values associated with FVD?
Increased osmolality, hematocrit, blood urea nitro, electrolytes, urine specific gravity.
Hypervolemia is caused by..?
Hypervolemia = Too much volume in the vessels (veins).
Caused by excess of fluid.
Hypovolemia treatment:
Replace fluid! Done orally or IV.
Hypervolemia is caused by..?
Heart failure, kidney dysfunction, cirrhosis, increased sodium intake.
What are some signs and symptoms of FVE?
FVE = Think big and bulging body.
Weight gain = Water gain
Cardiovascular = Hypertension, bounding pulses, tachycardia
Integumentary = Edema, pale cool skin
Neuromuscular = Weakness, altered level of consciousness, headache
Renal & urinary = Increased urine output & decreased urine output when kidney issues are present
Respiratory = Rapid and shallow respirations, moist crackles (fluid in lungs - pulmonary edema)
Gastrointestinal = Diarrhoea, enlarged liver, abdo fluid.
Hypervolemia treatment:
Low sodium diet, do daily I & O’s, take daily weights, medications such as diuretics, place pt in high-semi Fowler’s position.
What are some abnormal lab values associated with FVE?
Reduced osmolality, hematocrit, blood urea nitro, electrolytes, urine specific gravity.
Whats the saying with sodium as to why it causes FVE?
Where sodium goes, water flows, so sodium makes us retain fluids.
Which out of the several electrolytes are important for body functioning?
o Sodium (Na+)
o Chloride (Cl–)
o Bicarbonate (HCO3–)
o Calcium (Ca2+)
o Potassium (K+)
o Phosphate (PO42–)
o Magnesium (Mg2+)
