Fluid Volume Deficit/Excess Focused Study Guide
Hypotonic fluids
0.45% sodium chloride
Isotonic fluids
0.9% sodium chloride
Answer: 3 Rationale 1: Poor skin turgor is associated with fluid volume deficit.Rationale 2: Decreased urine output is associated with fluid volume deficit.Rationale 3: Circulatory overload causes manifestations such as a full, bounding pulse; distended neck & peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs; pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which dilution of plasma by excess fluid causes a decreased hematocrit & blood urea nitrogen (BUN); & possible cerebral edema.Rationale 4: Increased hemoglobin & hematocrit values are associated with fluid volume deficit.
A postoperative pt is diagnosed with fluid volume overload. Which of the following should the nurse assess in this pt? 1. poor skin turgor 2. decreased urine output 3. distended neck veins 4. concentrated hemoglobin & hematocrit levels
Answer: 3 1: The pt should avoid prolonged standing.Rationale 2: Bed rest can promote skin breakdown.Rationale 3: The pt needs to be taught how to avoid orthostatic hypotension which would include assisting & teaching the pt how to move from one position to another in stages.Rationale 4: A physician referral is needed for physical therapy intervention & is not indicated in this situation.
A postoperative pt with a fluid volume deficit is prescribed progressive ambulation yet is weak from an inadequate fluid status. What can the nurse do to help this pt? 1. Assist the pt to maintain a standing position for several minutes. 2. This pt should be on bed rest. 3. Assist the pt to move into different positions in stages. 4. Contact physical therapy to provide a walker
Answer: 1 1: Antidiuretic hormone & aldosterone levels are commonly increased following the stress response before, during, & immediately after surgery. This increase leads to sodium & water retention. Adding more fluids intravenously can cause a fluid volume excess & stress upon the heart & circulatory system.Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid volume deficit, & stress upon the heart & circulatory system.Rationale 3: Seizure activity would more commonly be associated with electrolyte imbalances.Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid administration.
A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication? 1. fluid volume excess 2. fluid volume deficit 3. seizure activity 4. liver failure
1 Rationale 1: The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain & heart.Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output.Rationale 4: The manifestations reported are not indicative of cardiac failure in this pt.
A pt, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale, cool skin, & decreased urine output. The nurse realizes these findings are most likely a direct result of which of the following? 1. the body's natural compensatory mechanisms 2. pharmacological effects of a diuretic3 . effects of rapidly infused intravenous fluids 4. cardiac failure
Pulmonary edema Signs and Symptoms
Acute repository distress
Pulmonary edema Management
Administer diuretics
Fluid Volume Excess Management
Administer diuretics -If you can only do one thing do this FIRST
Pulmonary edema Management
Administer oxygen, positive airway pressure and/or possible intubation and mechanical ventilation
Fluid Volume Excess Management
Administer supplemental oxygen as prescribed
Answer: 1 Rationale 1: The home care nurse should instruct this pt about ways to decrease dependent edema, which include wearing support hose, elevating feet when in a sitting position, & resting in a recliner or bed with extra pillows.Rationale 2: The pt should elevate the legs.Rationale 3: As long as the shoes are well fitting, there is not reason to avoid wearing them.Rationale 4: It is appropriate for the pt to use extra pillows to keep the head up while sleeping.
An elderly pt is at home after being diagnosed with fluid volume overload. Which of the following should the home care nurse instruct this pt to do?1. Wear support hose. 2. Keep legs in a dependent position. 3. Avoid wearing shoes while in the home. 4. Try to sleep without extra pillows.
Fluid Volume Deficit Signs and Symptoms
Anorexia
Pulmonary edema Signs and Symptoms
Anxiety
Fluid Volume Excess Signs and Symptoms
Ascites -Accumulation of serous fluids in the peritoneal (abdominal) cavity
Fluid Volume Deficit Management
Assess I&O
Fluid Volume Deficit Management
Assess O2 saturation
Fluid Volume Deficit Management
Assess breath sounds
Fluid Volume Deficit Management Pulmonary edema Signs and Symptoms
Assess for change in LOC
Fluid Volume Deficit Management
Assess for decreased central venous pressure
Fluid Volume Deficit Management
Assess for weight loss
Fluid Volume Deficit Management
Assess skin turgor for tenting
Fluid Volume Deficit Management
Assess vital signs -Blood pressure most important -Orthostatic hypotension
Fluid Volume Excess Signs and Symptoms
Bad kidney's -Oliguria
Fluid Volume Deficit Signs and Symptoms Pulmonary edema Signs and Symptoms
Change in LOC
Fluid Volume Excess Signs and Symptoms
Confusion
Pulmonary edema Signs and Symptoms
Cough
Fluid Volume Excess Signs and Symptoms
Crackles in lungs
Primary Pulmonary edema Signs and Symptoms
Crackles in lungs
Fluid Volume Excess Labs
Decreased BUN -8-20 mg/dL
Fluid Volume Deficit Signs and Symptoms
Decreased Blood pressure -Orthostatic Hypotension
Fluid Volume Excess Labs
Decreased Urine specific gravity -1.010-1.030
Fluid Volume Deficit Signs and Symptoms
Decreased central venous pressure
Fluid Volume Excess Labs
Decreased hematocrit -Men: 42-52% -Women: 37-47%
Fluid Volume Deficit Signs and Symptoms
Decreased pulse -Weak pulse
Fluid Volume Deficit Signs and Symptoms
Decreased skin turgor -Tenting
Fluid Volume Deficit Signs and Symptoms
Decreased urine output
Fluid Volume Deficit Education
Develop treatment plan -Medication, -Hydrations, -Dietary restrictions
Fluid Volume Deficit Signs and Symptoms
Dry mucous membranes
Pulmonary edema Signs and Symptoms
Dyspnea at rest
Isotonic Hypervolemia
ECF volume becomes elevated; ICF remains normal
Fluid Volume Excess Signs and Symptoms
Edema
Fluid Volume Deficit Management
Encourage oral fluids
Fluid Volume Deficit Education
Encourage to drink fluids frequently
Fluid Volume Deficit Signs and Symptoms
Fatigue
Fluid Volume Deficit Signs and Symptoms
Flattened neck veins
Isotonic dehydration
Fluid deficit caused by a decrease in plasma volume
Isotonic dehydration
Fluid lost is only from vascular and interstitial spaces (ECF)
Fluid Volume Deficit Signs and Symptoms Fluid Volume Excess Signs and Symptoms
General/muscle weakness
Fluid Volume Excess Signs and Symptoms
Good kidney's -Increased urine output
Fluid Volume Excess Signs and Symptoms
Headache
Pulmonary edema Management
High fowlers position
2nd line choice for Fluid Volume Deficit Management
Hypotonic solution -0.45% sodium chloride
Fluid Volume Deficit complication
Hypovolemic Shock
Isotonic Hypervolemia
ICF remains normal
Fluid Volume Deficit Labs
Increased BUN -8-20 mg/dL
Fluid Volume Excess Signs and Symptoms
Increased Central venous pressure
Fluid Volume Deficit Signs and Symptoms Pulmonary edema Signs and Symptoms
Increased HR -Tachycardia
Fluid Volume Deficit Labs
Increased Hematocrit -Men: 42-52% -Women: 37-47%
Fluid Volume Excess Signs and Symptoms
Increased Pulse -Bounding
Fluid Volume Deficit Labs
Increased Urine Specific Gravity -1.010-1.030
Fluid Volume Excess Signs and Symptoms
Increased blood pressure
Fluid Volume Excess Signs and Symptoms
Increased neck swelling -JVD distention
Fluid Volume Deficit Signs and Symptoms
Increased respiration rate
Fluid Volume Excess Signs and Symptoms
Increased respirations -Crackles -Shortness of breath
Fluid Volume Excess Signs and Symptoms
Increased temperature
Pulmonary edema Signs and Symptoms
Increased vein distention
Most common Fluid Volume Deficit Type
Isotonic Dehydration -80% of cases
Most common Fluid Volume Excess Type
Isotonic Hypervolemia
1st line choice for Fluid Volume Deficit Management
Isotonic fluids
Isotonic fluids
Lactated Ringers
Fluid Volume Excess Signs and Symptoms
Lethargy
Isotonic dehydration
Little or no change in the concentration of water and sodium in the blood stream
Fluid Volume Excess Management
Monitor breath sounds -Crackles
Fluid Volume Excess Management
Monitor daily weight gain
Fluid Volume Deficit Signs and Symptoms
Nausea/vomiting
Fluid Volume Deficit Signs and Symptoms
Pale -Cool -Clammy skin
Primary Pulmonary edema Signs and Symptoms
Pink frothy sputum
Fluid Volume Excess Management
Position the client in semi fowler's position
Fluid Volume Deficit Management
Provide IV fluids -Isotonic fluids -Lactated ringers -0.9% sodium chloride
Fluid Volume Excess complication
Pulmonary edema
Fluid Volume Excess Management
Put on sodium restricted diet
Fluid Volume Excess Management
Reposition the client at least every 2 hs
Fluid Volume Excess Management
Restrict fluids
Fluid Volume Excess Signs and Symptoms
Seizures
Fluid Volume Deficit Signs and Symptoms
Sunken eyeballs
Fluid Volume Deficit Signs and Symptoms
Sunken fontanels in infants
Fluid Volume Deficit Signs and Symptoms
Temperature within normal limits or slightly elevated
4 IV 5% dextrose in water to run at 250 mL/hr. To correct hypovolemic shock with dehydration, the client needs IV fluids that are isotonic and will increase intravascular volume, such as normal saline. With D5W, the body rapidly metabolizes the dextrose and the solution becomes hypotonic. All of the other interventions are appropriate for a client with shock
The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the health care provider should the RN question? 1. Blood pressure every 15 minutes. 2. Place two 18-gauge IV lines. 3. Oxygen at 3 L via nasal cannula. 4. IV 5% dextrose in water to run at 250 mL/hr.
4. Administer furosemide 40 mg IV push. Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important but are not urgent.
The health care provider has written these orders for a client with a diagnosis of pulmonary edema. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lbs, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? 1. Weight the client every morning. 2. Maintain accurate intake and output records. 3. Restrict fluids to 1500 mL/day. 4. Administer furosemide 40 mg IV push.
4 A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased CVP, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration (fluid volume deficit) has a low CVP. The assessment findings in the remaining options are seen in a client with fluid volume excess.
The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1.Lung congestion 2.Decreased hematocrit 3.Increased blood pressure 4.Decreased central venous pressure (CVP
2 Focus on the subject fluid volume excess. Read each option and think about the fluid imbalance that can occur in each. Clients taking diuretics or having ileostomies or gastrointestinal suctioning all lose fluid. The only condition that can cause an excess is the condition noted in the correct option.
The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1.The client taking diuretics 2.The client with kidney disease 3.The client with an ileostomy 4.The client who requires gastrointestinal suctioning
1 A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy, or a client receiving frequent wound irrigations, are most at risk for fluid volume excess
The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1.A client with an ileostomy 2.A client with heart failure 3.A client on long-term corticosteroid therapy 4.A client receiving frequent wound irrigations
3 A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present?1.Weight loss 2.Flat neck and hand veins 3.An increase in blood pressure 4.Decreased central venous pressure (CVP)
a. Fluid volume excess Edema is a characteristic sign of fluid volume excess (hypervolemia). Metabolic acidosis and hyponatremia are not directly associated with the development of peripheral edema.
The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of what?a. Fluid volume excess b. Hyponatremia c. Metabolic acidosis d. Hypovolemia
Isotonic Hypervolemia
There is little or no change in the concentration of electrolytes and water in the blood stream
Fluid Volume Deficit Signs and Symptoms
Thirst
Fluid Volume Excess Priority Intervention
Treat with O2 and diuretics
Isotonic Hypervolemia
Water is neither pulled from the cells into circulation or pulled from circulation into the cells
Fluid Volume Deficit Education
Ways to prevent dehydration
Fluid Volume Excess Signs and Symptoms
Weight gain
Fluid Volume Deficit Signs and Symptoms
Weight loss
A An infant has considerably more total-body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits.
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? a. An infant age 4 months b. A man age 86 years c. A woman age 45 years d. An adolescent age 17 years
Answer:d. 0.45% NaClRationale:0.45% NaCl is hypotonic, while normal saline and Lactated Ringer's are isotonic. 5% dextrose in 0.45% NaCl is hypertonic.
Which of the following commonly used intravenous solutions is hypotonic? a. 5% dextrose in 0.45% NaCl b. 0.9% NaCl c. Lactated Ringer's d. 0.45% NaCl
Answer:1) 0.9% NaCl (normal saline) Rationale:Hypovolemia occurs when there is a proportional loss of water and electrolytes from the extracellular fluid. Normal saline is an isotonic fluid that remains inside the intravascular space, thus increasing volume. Solutions of 0.45% NaCl and D5W are hypotonic fluids and therefore would pull body water from the intravascular compartment into the interstitial fluid compartment, leading to cellular death. Dextran is a hypertonic fluid that pulls fluid and electrolytes from the intercellular and interstitial compartments into the intravascular compartment and can be used in cases of hypovolemia but is not considered as a first choice.
Which of the following is considered a first-line intravenous solution for a patient with hypovolemia? 1) 0.9% NaCl (normal saline) 2) 0.45% NaCl (½ normal saline) 3) Dextran (a plasma expander) 4) D5W (5% dextrose in water)