Hypovolemia / Hypervolemia

Phase 1 of third spacing

48-72 hours --> fluid into intertitial spaces

A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. Urine is concentrated with a high specific gravity. Which of the following are manifestations of fluid volume deficit for which the nurse should monitor? (Select all that apply.) A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low‑grade fever E. Tachypnea

A B D E

A nurse is admitting an older adult client who is experiencing dyspnea, weakness, weight gain of 2 lb, and 1+ bilateral edema of the lower extremities. The client has temperature 37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply.) A. Dyspnea B. Edema C. Bradycardia D. Hypertension E. Weakness

A B D E

Solvent

A liquid that contains a substance in solution

Anion

A negatively charged ion

Cation

A positively charged ion

Solute

A substance dissolved in a solution

How much fluid do we get a day from the krebs cycle?

About a cup a day (water from oxidation)

Hyper

Above, beyond, excessive

What affects body fluid?

Age (elderly) Gender (Men have more)

When hypervolemia occurs what happens to the Hct, Hgb, Urine specific gravity, serum sodium, serum osmolality and BUN? (Increase or Decrease?)

All tests will decrease Hemodilution

When hypovolemia occurs what happens to the Hct, Urine specific gravity, serum sodium, serum osmolality and BUN? (Increase or Decrease?)

All tests will increase BUN= >25 mg/dL due to Hemoconcentration Specific Gravity= >1.030 Serum Sodium = >145 mEQ/L Serum Osmolality = >295 mOsm/kg

Manifestations of Pulmonary Edema

Anxiety tachycardia Increased vein distention Premature ventricular contractions Dyspnea at rest Change in LOC Restlessness Lethargy Ascending crackles Cough productive of frothy pink-tinged sputum

Expected findings - Hypervolemia: Gastrointestinal

Ascites

Client education for EFV

Avoid sweet or dry foods (cause thirst) How to measure intake at home Weigh daily (contact dr if gaining 2 lbs per week, pitting edema or SOB)

Inter

Between

Complications of EFV

Circulatory overload HTN Edema (Takes 3 liters of excess fluid before edema is observed)

Expected findings - Hypervolemia: Respiratory

Crackles Cough Increased respiratory rate Dyspnea (caused by excess fluid within the body and lungs)

Clinical manifestations of EFV

Crackles Weight gain HTN Bounding pulse Increase HR Diluted urine Dependent Edema JD Distended hand veins

A nurse is assessing a client who is dehydrated for fluid volume deficit. Which of the following findings should the nurse expect in the client? A. Moist skin B. Distended neck veins C. Increased urinary output D. Tachycardia

D

A nurse is caring for an older adult client in a long‑term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. The client's temperature is 38.3° C (100.9° F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take? A. Initiate fluid restrictions to limit intake. B. Observe for signs of peripheral edema. C. Encourage the client to ambulate to promote oxygenation. D. Monitor for orthostatic hypotension

D

DFV

Deficient fluid volume (hypovolemia)

Who has the most orthostatic hypotension?

Dehydrated people

What is the client at risk for due to fluid overload?

Developing pulmonary edema or congestive heart failure.

Management of EFV (3 D)

Digoxin Diuretics Diet - Low Na+ Dialysis (if in renal failure)

Expected findings - Hypovolemia: Other Findings

Diminished Cap Refill Cool, clammy skin Diaphoresis Sunken eyeballs Flattened neck veins Poor skin turgor/tenting Weight loss Low central venous pressure

Expected findings - Hypovolemia: Neuromusculoskeletal

Dizziness Snycope Confusion Weakness Fatigue

Iso

Equal

EFV

Excess fluid volume (hypervolemia)

Expected findings - Hypernatremia or Osmolality imbalances

Extreme thirst Skin that is dry and flushed Postural hypotension Fever Restlessness, confusion, agitation Coma & seizures can occur

Contributing factors of EFV

Fluid intake greater than output Excessive oral fluid intake Rapid infusion of IV fluids HF Renal disease Adrenal disease Excessive salt intake Steroid drugs

Insensible fluid loss

Fluid loss cannot be measures by ordinary means, but computers can usually calculate it. (IE perspiration, feces, lungs)

Causes of Hypervolemia

Heart failure Kidney disease Cirrhosis Overdose of sodium concentrated fluids Fluid shifts in burns Prolonged use of corticosteroids Severe stress Hyperaldosteronism

Examples of Osmolality imbalances?

Hypernatremia (water deficit) Hyponatremia (Water excess)

Complications of third spacing

Hypovolemia Hypotension Shock Death

What should the nurse monitor for patients with hypervolemia?

I & O's Daily weight Assess breath sounds Peripheral edema Sodium-restricted diet as prescribed Fluid restriction (if prescribed) Encourage rest Position in semi-fowlers Na+ & K+ levels

What should the nurse monitor for patients with hypovolemia?

I & O's Vital signs (including orthostatic) Changes in mental status, confusion Weight Gait stability

Management of third spacing

IV fluids IV Colloids

BNP Test

If elevated - person has CHF

What organs does fluid output occur?

Kidneys Skin Lungs GI Tract

Examples of Crystalloids

Lactated ringers Normal saline

Dehydration

Low fluid volume of BOTH the extracellular & the Intracellular fluid

Important teaching to clients with heart disease or impaired kidney function.

Low sodium diet Restrict fluid intake

Hypovolemia

Low volume of the extracellular fluid (specifically the fluid in the intravascular space)

Electrolyte

Molecules which, when dissolved in solution, dissociate into electrically charged atoms called ions

Contributing factors that cause deficient fluid volume

N/V Insensitivity to thirst Severe mental illness Neurological conditions Anxiety Wired jaw Oral trauma NPO Wound Fistula & Ostomy GI Suction Burns

What age group has the lowest percentage of total body water?

Obese elderly women

Expected findings - Hypovolemia: Renal

Oliguria (Decreased production & concentration of urine)

Extra

Outside

Expected findings - Hypervolemia: Other Signs

Peripheral edema due to excess of fluids within body & lungs, resulting in weight gain, distended neck veins, and increased urine output.

What age group has the highest percentage of total body water?

Premature Newborns

Purposes of body fluid?

Removal of waste products Cushioning and protections of organs Lubrication and insulation Provide structure and resilience to skin

Management of DFV

Replace fluids (orally or IV - Normal saline/lactated ringer)

Intervention for EFV

Reposition client every 2 hours Elevate legs Special mattress Ankle pumps Do not massage reddened areas Handle skin carefully

Phase 2 of third spacing

Resorption into intravascular space

Late clinical manifestations of EFV

Respiratory distress Increased RR Pulmonary edema Anxiety HF Shock Death

First symptom of dehydration?

Restlessness & Anxiety

Clinical manifestations of third spacing

Same as hypovolemia - EXCEPT weight GAIN (fluid is not actually lost from body) Ascities Anasarca Brawny Edema

complications of DFV

Shock, ATN, Increased Coagulability, Angina

Expected findings - Hypervolemia: Vital Signs

Tachycardia Bounding pulse Hypertension Tachypnea Increased central venous pressure

Expected findings for Hypovolemia: Vital Signs

Tachycardia Tready pulse Hypotension Orthostatic Hypotension Decreased central venous pressure Tachypnea Hypoxia

Permeability

The capability of a substance, molecule or ion to diffuse through a membrane

Brawny Edema

The edema is so excessive that the fluid cannot be displaced so there is no pitting. The tissues feel hard and skin is shiny and taut

Osmotic pressure

The pull exerted by electrolytes, which draws the solvent through the semipermeable membrane.

Colloidal (Oncotic)

The pull exerted by substances with a high molecular weight (IE Albumin). A colloid will draw water towards itself, keeping fluid within the intravascular space.

Expected findings - Hypovolemia: Gastrointestinal

Thirst Dry furrowed tongue Nausea Vomiting Anorexia Acute weight loss

Clinical manifestations of DFV

Thirst Poor skin turgor (tenting) Cracked skin & mucous membranes Sunken eyes Decreased urine output Increased specific gravity Weight loss Orthostatic hypotension Increase HR, Temp Weak pulse Prolonged capillary refill Apprehension, restlessness, fatigue

Hypo

Under, beneath, deficient

Causes of Volume Imbalances?

Vomiting, Nasogastric suctions & Diarrhea Diaphoresis Diuretic therapy, Diabetes Insipidus, Kidney disease, Adrenal insufficiency, Osmotic diuresis Third spacing - peritonitis, intestinal obstruction, ascites, burns Hemorrhage Altered intake (NPO)

Expected findings - Hypervolemia: Neuromuscular

Weakness due to excess fluid retained Headache Altered LOC

Why do Osmolality imbalances occur?

When body fluid becomes either hypertonic or hypotonic.

Why do volume imbalances occur?

When too little or too much isotonic fluid is present.

Examples of Colloids

Whole blood Packed RBC's Plasma Synthetic plasma expanders

Intra

Within

Sensible fluid loss

fluid loss that can be measured by ordinary means (IE urine in a graduate)

Anasarca

the entire body is very edematous