Fluid volume excess Flashcards
Common causes of fluid volume excess?
- Excessive water or IV fluid intake (especially hypotonic solutions)
- kidney dysfunction
*Heart failure
*SIADH (syndrome of inappropriate anti diuretic Hormone) body retains excess water
*Use of hypotonic fluids like D5W
Nursing interventions you could perform on someone with fluid overload?
- administer diuretics
- elevate extremities
- monitor vital signs (check for ↑ bp, respiratory rate, and hr)
*Assess daily weights
*Fluid restriction - assess lung sounds
Monitor intake and output closely
Clinical signs of fluid volume excess?
*Edema
* tachycardia
* hypertension
*Tachypnea
*Crackles in lungs
* weight gain
* Jugular vein distention
Which electrolyte imbalance can occur if someone is overhydrated with too much hypotonic fluid?
Hyponatremia
When someone gets too much hypotonic fluid, it dilutes the sodium in the bloodstream
Hypo + hypotonic= hyponatremia.
What are key vital sign changes expected on someone with fluid volume excess?
- increased heart rate
- increased blood pressure
*Bounding pulse
*↑ central venous pressure - crackles in lungs
What labs would you expect to be decreased in a patent with fluid volume excess?
*↓ sodium
* ↓ urine specific gravity
* ↓ hematocrit
* ↓BUN
* ↓ osmorality
What major complication du we worry about in patients with sever fluid volume excess?
Pulmonary edema = fluid leaking in lungs, causing impaired gas exchange
What is the difference between hypervolemia and overhydration?
- Hypervolemia is excess fluid and electrolytes (usually water + sodium, 50 it stays isotonic)
- Over hydration is excess water alone, which dilutes electrolytes (think : water intoxication or hypotonic overload)
What are some clinical manifestations of hypervolemia?
Bounding pulse, hypertension, crackles, edema
What are key nursing interventions for fluid volume excess?
Diuretics, fluid/sodium restriction, monitor daily weight, assess lung sounds.
What is a major complication of hypervolemia
Pulmonary edema
What positions should you place a hypervolemia client in to improve breathing?
Semi-Fowler or Fowler
What assessment findings differentiate fluid volume deficit from fluid volume excess?
FVD: sunken eyes, poor skin turbot, tachycardia
FVE: JVD, crackles, bounding pulse.
NOrmal range for blood osmolality
275-295
Name 3 causes of overhydration
SIADH
Excessive water intake
Excessive administration of hypotonic IV FLUIDS
What position should you place a client with pulmonary edema?
High Fowlers position
What are neuromuscular findings in fluid volume excess?
Weakness, visual changes , paresthesia, altered LOC
What diagnostic tool can reveal pulmonary congestion?
Chest x-ray
What dietary restriction is common for clients with hypervolemia?
Sodium restriction
What are early signs of pulmonary edema
Anxiety, dyspnea at rest, crackles, pink frothy sputum
What action should a nurse take to prevent skin breakdown in a hypervolemia patient?
Reposition every 2 hrs and use a pressure reducing mattress
What does bounding pulse and JVD indicate?
Fluid volume excess (Hypervolemia)
