Fluid imbalances (Fluid volume excess & fluid volume deficit)

Question 1

Fluid Volume Excess:

Answer 1

Excess ECF volume due to: Heart failure, renal failure, cirrhosis(liver disease), increased Na retention (salty diet, kidney disease), Excess IV fluids, decreased albumin.

Question 2

Assessment Findings for Hypervolemia (Fluid Volume Excess)

Answer 2

↑Pulse bounding (may be normal) ↑BP ↑peripheral edema, ↑ ascites, distended neck veins ↑weight >2lbs /24 hrs ↑crackles in lungs(pulmonary edema), cough, can have pink-tinged frothy sputum ↑Respirations and ↑ dyspnea, orthopnea ↑risk for skin breakdown, tissue that is stretched. Often have cool, pale skin ↑confusion(potential), weakness.

Question 3

Potential complication of fluid excess

Answer 3

A potential complication is pulmonary edema. Pulmonary edema involves fluid in the interstitial space of the lung that causes problems with gas exchange

Question 4

Fluid volume excess labs and assessment findings

Answer 4

Labs all DOWN:
↓hematocrit (blood has more fluid than normal and is diluted)
↓serum osmolarity
↓BUN (shows overhydration)
↓sodium (usually decreased due to dilution)
↓glucose
↓urine specific gravity (> 1.030, light/clear urine)

Assessment Finding all UP:
Increased Pulse, BP, CVP, confusion, edema, weight, ascites, crackles, RR, dyspnea, orthopnea, JVD, skin breakdown

Question 5

Hypervolemia: Nursing

Answer 5

*Monitor strict I&Os!!
*Daily weights!! (>2lbs in 24 hrs)
*Consider fluid restrictions
*Reduce salt intake
*Monitor airway/breathing: O2 support if needed
*Administer diuretics as prescribed
*Monitor edema (importance of positioning)

RESTRICT!!
Reduce IV flow rate
Evaluate breath sounds, ABGs, sats, CXR, CBC, edema
Semi-fowlers position
Treat w O2 & diuretics A/O
Reduce fluid & salt intake
I&O, daily weight, implement restriction
Circulation, color, edema
Turn & position q2

Question 6

Evaluation of fluid volume excess

Answer 6

VS WDL, trends
No dyspnea, orthopnea
Lungs clear, no wheezing
No cough or pink-tinged sputum
No edema
Weight within 2 lbs of defined limits, trends
No skin breakdown
Electrolyte imbalances (mainly sodium, potassium, calcium, and magnesium)

Question 7

Fluid Volume Deficit:

Answer 7

Decreased ECF volume due to: Excessive GI loss (V/D, NG suctioning), Skin loss (sweating/diaphoresis), Renal loss (diuretics, kidney/adrenal issues), Fluid shifts (third spacing, burns), Trauma/hemorrhage, Altered intake

Question 8

Assessment Findings for Hypovolemia (fluid volume deficit):

Answer 8

Dry mucous membranes -↑ thirst (early/moderate sign)(remember may be absent in elderly)
Decreased skin turgor (tenting-not valid with older adults
Decrease in Blood Pressure (watch for syncope)
Decreased fluid to pump so HR is↑(tachycardia)
Decreased urine output!!
Decrease in weight !! (1 liter of fluid equals around 1 kg in weight, or 2.2 lbs)
Decrease (in later stages) of perfusion to brain → LOC changes
Hypovolemic shock (will learn more later)

Question 9

Fluid volume deficit labs and assessment findings

Answer 9

Assessment finding: ​​*Dry mucous membranes -
↑ thirst (early/moderate sign) *Decreased skin turgor (tenting). Remember that thirst mechanism may be absent in the elderly, and tenting may be a normal finding for them.
*Decrease in Blood Pressure (hypotension) oMay have orthostatic hypotension
*Decreased fluid to pump so HR is↑ (tachycardia), thready pulse *Decreased urine output (<30mL/hr) *Decrease in weight *Decrease (in later stages) of perfusion to the brain → LOC changes, restlessness, capillary refill greater than 4 seconds.

Laboratory findings:
↑hematocrit (because blood has less fluid and is concentrated)
↑serum osmolarity
↑BUN (shows dehydration)
↑sodium (usually increased because of fluid loss)
↑glucose
↑urine specific gravity (>1.030, darker urine)

Question 10

Nursing Actions and Interventions:

Answer 10

Fluid replacement (isotonic IVFs, blood if patient has experienced blood loss)
Evaluate LOC (safety)
Monitor urine output / I & O – report trends. Evaluate urine(< 30 mL/hr, dark color)
Daily weights
Safety - position changes slowly, orthostatic changes
Shock position (back with legs ↑) WHY??
Skin care

FLUIDS!!
Fluids – PO, isotonic, blood
LOC(assess)
Urine output – ↓ trends
I&O–IV fluids A/O
Document VS, wt, monitor for trends
Safety –Shock position

Discharge teaching – fluid intake, monitor UOP
Daily weight

Question 11

Evaluation of fluid volume overload

Answer 11

Evaluation: No ↓ weight, No ↓ moisture mucus membranes, No ↓ vascular volume (HR WDL), No ↓ postural BP, Neck veins not flat, Adequate UOP, Stable BP, No ↓ in skin turgor