QUIZ 2: FLUID VOLUME DEFICIT Flashcards
There are different fluid volume disturbances that may affect an individual.
Fluid volume disturbances
occurs when loss of ECF volume exceeds the intake of fluid.
Fluid volume deficit
refers to an isotonic volume expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF.
Fluid volume excess
refers to a serum sodium level that is less than 135 mEq/L
Hyponatremia
is a serum sodium level higher than 145 mEq/L.
Hypernatremia
usually indicates a deficit in total potassium stores.
Hypokalemia
refers to a potassium level greater than 5.0 mEq/L.
Hyperkalemia
CALCIUM levels below 8.6 mg/di.
Hypocalcemia
is a calcium level greater than 10.2 mg/dl.
Hypercalcemia
refers to a below-normal serum magnesium concentration.
Hypomagnesemia
is a serum phosphorus level that exceeds 4.5 mg/di in adults.
Hyperphosphatemia
Disturbances in electrolyte balances
Hyponatremia
Hypernatremia
Hypokalemia
Hyperkalemia
Hypocalcemia
Hypercalcemia
Hypomagnesemia
Hypermagnesemia
Hypophosphatemia
Hyperphosphatemia
Complications of fluid and electrolyte imbalances
DCSC
Dehydration
Cardiac overload
Siadh / syndrome of inappropriate secretion of antidiuretic hormone
Cardiac arrest
Fluid volume deficit would result in dehydration of the body tissues.
Dehydration
Fluid volume excess could result in cardiac overload if left untreated.
Cardiac overload
Siadh MEANING
syndrome of inappropriate secretion of antidiuretic hormone- is a disorder of impaired water excretion caused by the inability to suppress the secretion of antidiuretic hormone (adh).
Assessment and diagnostic findings
BUN .
Hematocrit
Physical examination
Serum electrolyte levels.
ECG.
ABG
Medical Management
Isotonic electrolyte solutions.
Accurate I&O.
Dialysis
Nutritional Therapy
Pharmacologic therapy
AVP receptor agonists.
Diuretics.
IV calcium gluconate.
Calcitonin.
is also a potent vasoconstrictor and exerts a direct constrictive action on specific smooth muscle receptors
Vasopressin
Nursing management
Close monitoring
I&O.
Daily weight. Assess the patient’s weight daily to measure any gains or losses.
Vital signs.
Physical exam. Physical exam is needed to reinforce other data about a fluid or electrolyte imbalance.
Nursing diagnosis
- Excess fluid volume related to excess fluid intake and sodium intake.
- Deficient fluid volume related to active fluid loss or failure of regulatory mechanisms.
- Imbalanced nutrition: less than body requirements related to inability to ingest food or absorb nutrients.
- Imbalanced nutrition: more than body requirements related to excessive intake.
Nursing interventions for fluid & electrolyte imbalances
Monitor turgor.
Urine concentration.
Oral and parenteral fluids.
Oral rehydration solutions.
Central nervous system changes.
Diet.
occurs when loss of extracellular fluid exceeds the intake of fluid.
Hypovolemia
It is a state or condition where the fluid output exceeds the fluid intake. It occurs when the body loses both water and electrolytes from the ECF in similar proportions.
Hypovolemia
Predisposing factors: Hypovolemia
DAOHCT
Diabetes Insipidus
Adrenal insufficiency
Osmotic diuresis
Hemorrhage
Coma
Third-space fluid shifts
Signs and symptoms: hypovolemia
LTDOCIADC
Low BP (Postural hypotension)
Tachycardia: rapid weak & thready pulse
Decreased skin turgor
Oliguria
Concentrated urine Flattened neck veins
Increased temperature
Acute weight loss
Decreased central venous pressure
Cool, clammy skin (due to peripheral vasoconstriction
Signs and symptoms (Infant and young children)
CNBIS
Crying without tears
No wet diapers for three hours or more
Being unusually sleepy or drowsy
Irritability Eyes that look sunken
Sunken fontanel
Causes: hypovolemia
Abnormal fluid losses
- Vomiting
- Diarrhea
- Gastric suctioning
- Sweating
- Bleeding
Decrease intake
- Nausea
- Lack of access to fluids
- Osmotic diuresis
3rd-space fluid shifts
- Edema formation in Burns
- Ascites in liver dysfunction
Diabetes Insipidus
Diagnosis: Blood test:
CBC - increase Hematocrit level
Elevated BUN - Out of proportion with creatinine
Imbalance serum K+, Na+
Diagnosis: Urine Test
Increase BUN, Creatinine
Na+ concentration
Urine pH
Xray/ MRI - Hypovolemic shock with subtle imaging signs
possibly evidenced by:
Abdominal distention.
Confusion, restlessness.
Dark concentrated urine.
Decreased urine volume.
Decreased central venous pressure.
Hypotension.
Pale, moist, clammy skin.
Tachycardia.
Tachypnea.
Weak pulses
Nursing assessment
Complete a thorough head-to-toe assessment.
Assess intake and output.
Assess vital signs.
Assess laboratory values.
Assess skin turgor.
Assess urine color and concentration.
Auscultate cardiac sounds.
Assess cardiac rhythm.
Assess mental status.
Treatment
Oral hydration and diet
IV Fluids
Isotonic electrolyte crystalloid solutions ( LR, 0.9% NSS)
then hypotonic electrolyte
Blood transfusion
Management
Monitor I & O, weight, vital signs, LOC, breath sounds, skin color to prevent fluid overload.
Fluid volume replacement accordingly.
CVP Monitoring
Fluid challenge test (due to prolonged FVD / to check renal blood flow.
Level of consciousness
ALOSC
Alert (conscious)
Lethargy
Obtundation
Stupor
Coma (unconscious)
Appearance of wakefulness, awareness of the self and environment
Alert (conscious)
mild reduction in alertness
Lethargy
moderate reduction in alertness. Increased response time to stimuli
Obtundation
Deep sleep, patient can be aroused only by vigorous and repetitive stimulation. Returns to deep sleep when not continually stimulated.
Stupor
Sleep lice appearance and behaviorally unresponsive to all external stimuli (Unarousable unresponsiveness, eyes closed)
Coma (unconscious)
CVP mean?
Central Venous Pressure-often used as an assessment of hemodynamic status.
3 stages of hypovolemic shock
Stage 1: 15% blood loss
(750 mL or about 25 ounces).
Stage 2: 15% to 30%
(750 mL to 1,500 mL or up to almost 51 ounces)
Stage 3: 30% to 40% of your blood
(1,500 to 2,000 mL or up to 68 oz.)
