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