Fluid Volume Deficit (FVD)
1. A decrease in total body water
Fluid Volume Deficit (FVD): Third Space Shift (with)
1. No actual loss of total body water
Fluid Imbalance: 3 factors that affect body fluids
1. Age
2. BMI
3. Gender
FVD or HYPOvolemia
1. A relatively common problem that may exist alone or in a combination with other electrolyte or acid-base imbalances.
2. Often causes a DECREASE in circulating blood volume that leads to inadequate tissue perfusion.
Causes of FVD
1. Abnomal Fluid Loss: Vomiting, diarrhea, sweating w/o fluid replacement, GI suctioning, chronic use of enemas.
2. Lack of Fluid Intake: Nausea or inablilty to gain access to fluids.
3. Other causes: Third Space Shifting or fluids: ASCITES, EDEMA
4. Additional Risk Factors: Diabetes insipdus, hemorrhage.
Manifestations of FVD: Depend on Severity of fluid loss
1. Hypotension
2. Tachycardia
3. Decreased venous filling
4. Dry mucous membranes
5. Decreased skin turgor
6. Concentrated urine
7. Decreased Urine Output (oliguria)
Overall goals for Client with FVD
1. ID client at risk (very young and old)
2. Correct underlying cause
3. Correct the existing deficits
Labs to Monitor with FVD
1. Serum lytes: Mainly watch serum Na+ and K+ levels
2. Serum Hematocrit: Levels INCREASE
3. Urine Specific Gravity= 1.010-1.030 (INCREASE)
4. Serum Osmolatity (INCREASE)
Normal Na+ levels
135-145 mEq/L
Normal K+ levels
3.5-5.0 mEq/L
Osmolality
Used to describe concentration of a solution: this concentration of a fluid affects the movement of H2O between fluid compartments by osmosis.
Manifestations of FVD
1. Oliguria, Concentrated urine
2. Weak, rapid pulse
3. Cool, clammy, pale skin
4. Capillary refill > 3 seconds
Severe Dehydration, Decrease in total body water, Renal Tubular Necrosis, and Diabetes Insipidus: How do these conditions affect serum Osmolality?
Increase in Serum Osmolaity > 300 mOs/L
Vomiting, Diarrhea, Sweating, Third spacing of fluids, Diabetes Insipidus, These are considered causes for which type of fluid imbalance?
Fluid Volume Deficit
Once FVD develops, the body tries to conserve fluids. What hormone is affecting this body response?
ADH
Identify the two main electrolytes the nurse will want to monitor with fluid volume deficit. Name the two body systems most affected by these changes.
Sodium and Potassium
GI system and Renal System
Medical Management of FVD
1. Mild to Moderate FVD: Oral fluid replacement
2. Acute to Severe FVD: IV replacement of fluids, IV rate (based on severity of fluid loss, hemo dynamic of client)
3. Severe FVD (caused by decreased renal function) fluid challenge
Fluid Challenge
100-200 ml of fluid infused over a short period of time to see if kidney is functioning well. If does not have output then renal or kidney problem
Medical Management for acute to severe FVD will consist of IV therapy. Identify the type of solution used, giving an example of this solution. Give 3 nursing assessments to perform in order to avoid fluid overload.
1. Isotonic solution= LR, D5W, 0.9%NS
2.I&O's, weight, VS, LOC, breath sounds, skin color
Give 3 nursing actions for the client with imparied oral mucous membranes secondary to fluid loss:
1. Frequent oral care; assess tongue turgor
2. Applying water soluble lubricant to lips
3. Assess color of gums
What is the normal reference range for Urine Specific Gravity? How does FVD effect the Urine Specific Gravity?
1. 1.010-1.030
2. FVD=increase/concentrated. kidneys try to conserve fluid.
Identify the test used to determine renal function in the client with severe FVD and Oliguria. Explain the test and it's goal.
Fluid Challenge Test
Volumes of fluid administered at specific rates and intervals.
Goals is to increase fluids for adequate tissue perfusion without causing CV collaspe.
Identify the complication that develops with rapid fluid volume loss
HYPOvolemic Shock
Identify what the nurse will be monitoring when evaluating the effectiveness of nursing care for the client FVD.
Tissue perfusion (cap refill, skin color, VS, moist gums, skin turgor, LOC, labs), fluid output
Identify a more accurate or valid assessment for detecting FVD in the elderly other than the assessment of skin turgor.
Assessment of venous filling in hands and feet. More effective because skin has lost elasticity.
Related Nursing Diagnoses and Goals for FVD
Fluid Volume Deficit
Decreased Cardiac Output
Impaired Oral Mucous Membrane
Fluid Volume Deficit (Identified Problem)
Goal
The client will have body fluids levels restored to WNL on/by (time frame)
Fluid Volume Deficit (AEB)
B/P and pulse rate WNL
Skin turgor < 3 sec
Urine Specific gravity < 1.030
Decreased Cardiac Output (Identifed Problem) Goal
The client will have cardiac output restored WNL with adequate O2 to vital organs on/by (time frame)
Decreased Cardiac Output (AEB)
B/P and pulse and quality WNL for client
Urine output of at least 30 cc/h maintained
Impaired Oral Mucous Membrane (Identifed problem)
Goal
The client will maintain moist mucouse membrane on/by(time frame)
Impaired Oral Mucous Membrane (AEB)
Absence of cracks on lips and tongue
Absence of coating on tongue
Nursing Interventions for Client with FVD
Fluid Volume Deficit- give antimetics,
Decreased Cardiac Output- Humified Oxygen, increase venous return
Impaired Oral Mucous Membrane- Saliva Substitute, clean lips, good oral care, tap water or NS rinses, do as often as client wants
With all Monitor I&O's. VS, specific gravity, Na an K levels, orthostatic HTN, see if client has increased thrist, weigh same time every day,
1 Liter of Water equals
1 kg or 2.2 lbs
Evaluation of Nursing Care in Client with FVD
The client should
1. Ingest adequate amount of fluids to restore hemodynamic state
2. Maintain fluid output appr. equal to fluid intake
3. Have urine output volumes WNL
4. State oral mucosa discomfort is relieved
5. Experience no oral mucosal complications
Clinical Signs of Dehydration Children
Mild
1. Weight loss infants-3% -5%
2. Weight loss children-3%-4%
3. Pulse-Normal
4. Respiratory rate-Normal
5. B/P-Normal
6. Behavior-Normal
7. Thirst-Slight
8. Mucous Membranes-Normal
9. Tears-Present
10. Anterior fontanel-Normal
11. External Jugular vein-Visible when supine
12. Skin- Cap refill> 2 sec
13. Urine Specific Gravity > 1.020
Clinical Signs of Dehydration: Moderate
1. Weight loss infants- 6%-9%
2. Weight loss children- 6%-8%
3. Pulse- slightly increased
4. Respiratory rate- Slight tachypnea (rapid)
5. B/P- Normal to orthostatic (>10 mm Hg change)
6. Behavior- Irritable, more thirsty
7. Thirst- Moderate
8. Mucous Membranes-Dry
9. Tears-Decreased
10. Anterior Fontanel- Normal to sunken
11. External jugular vein- Not visible except with supraclavical pressure
12. Skin-Slowed cap refill (2-4 seconds (decreased turgor))
13. Urine Specific Gravity- >1.020; Oliguria
Clinical signs of Dehydration: Severe
1. Weight loss infant- > or = 10%
2. Weight loss children- 10%
3. Pulse- Very increased
4. Respiratory rate- Hyperpnea ( deep and rapid)
5. B/P- Orthostatic to shock
6. Behavior- Hyperirritable to lethargic
7. Thirst- Intense
8. Mucous Membranes- Parched
9. Tears- Absent, sunken eyes
10. Anterior Fontanel- Sunken
11. External Jugular vein- Not visible even with supraclavical pressure
12. Skin- Very delayed cap refill (>4 sec ) and tenting, skin cool, acrocyanotic or mottled
13. Urine Specific Gravity- Pliguria or anuria
FVD Concerns for Pediatric Client
Infants- 70-80% of water is total body weight, less reserve, lose faster thru skin.
Diapers are weighed to determine output. 6-12 wet diapers per day is norm. 1ml=1gram. Give infant Pedialyte to help restore electrolyte is has diarrhea. Diarrhea needs to be replaced.
Children- Metabolic rate is faster. Need more water in to excrete metabolic waste. IV rate strictly controlled.
FVD Concerns for Elderly Client
Reduced cardiac, renal and respiratory function and reserve and alterations of body fluids to muscle mass may alter responses of elderly people to fluid and electrolyte changes and acid base disturbance.
Decreased respiratory function can impair pH regulation. Creatinine levels that are elevated indicate reduced renal function, multiple medications affect renal and cardiac function, routine use of laxatives and enemas, . FVD may cause delirium.
Hydrostatic and Osmotic Pressures are
Opposing forces normal fluid movement withing the ECF compartments depend on these two.
Routine procedures such as vigourous administration of laxatives or enemas prior to diagnostic studies may have produce their conditions, esp in elderly
FVD, Hypotension, Hypovolemia
Type of fluid spacing that indicate the accumulation of body fluid in extracellular space normally has not fluid or minimal fluid
Third spacing: Acites, Edema
Identify primary regulator of fluid intake that plays a major role in the prevention of dehydration?
Thirst
Normal references range for plasma osmolality
280-300 mOs/l
Solution with same osmolality in blood plasma called
Isotonic, 0.9%NS, D5W, LR
Na is in
Extracellular
Potassium is in
Intracellular
H2O excretion from the body is controlled by this hormone present or absent most significant in determining whether urine excretion is concentrated or diluted?
ADH
Produced and released by adrenal cortex in response to a decrease in plasma volume and decrease in in serum Na levels this hormone promotes H2O reabsorption by kidneys
Aldosterone
Lab tests evaluating fluid states normal range 1.010-1.025. Specifically used to measure kidneys ability to excrete or conserve H2O
Urine Specific Gravity
Made up of end product of protein metabolism this lab level varies with urine output. Factors that influence this lab value inclued decrease renal function, fever, dehydration
BUN 10-20 mg/dl
End product of muscular metabolism, very accurate indicator of renal function, serum levels of this lab value increase as renal function decreases.
Creatinine 0.7-1.4 mg/l
Body fluids normally move both these 2 major space in order to maintain homeostasis within the body
Intracelluar
Extracellular
What is electrolyte that is found primarly in ECF compartment and effects osmolality in ECF
Sodium
Since edema is common sign of FVE, client must be aware of meds that could cause edema. Identify 2 types of meds the nurse should teach this client to avoid.
Nsaids, Estrogens, Corticosteriods, antihypertensives, OTC meds
Fluid Volume Excess
Actual excess in total body water
Fluid excess is one or more body fluid spaces
FVE or HYPERvolemia
Expansion of ECF by abnormal retention of water and Na+ in equal proportions
FVE or HYPERvolemia is always secondary to
An increase in total body Na+ content
Which leads to an increase in total body water
Serum Na+ concentration remains normal
Causes of FVE
Circulatory Overload
Interstitual Edema
Causes of FVE: Contributing Factors
Heart Failure
Renal Failure
Cirrohosis of the liver
Excessive oral intake or table or sodium salts
Large amounts of IV fluids high in Na+
Manifestations of FVE
Edema; ANASCARA
Dyspnea, Shortness of Breath
Moist crackles (RALES) on auscultation
Increased B/P
Full bounding pulse
Jugular vein distention
Weight Gain
Altered LOC (disorentation, coma)
List 3 conditions that are considered Contributing Factors to FVE
Heart Failure
Renal Failure
Cirrhosis
These manifestations of which fluid imbalance:
Increased B/P, Anascara, Dyspnea, Jugular Vein Distention. Name 3 more
FVE
Rales, Weight gain, Altered LOC, Full bounding pulse
Overall Goals for Client with FVD
Identify client at risk
Correct the underlying cause
Correct the existing excess
Medical Managment of FVE
Limiting Na+ and water intake
Administration of diruretics
Restriction of Na+ in the diet
Labs to Monitor with FVE
Serum Electrolytes: Mainly watch Na+ and Osmolality (may decrease)
Serum Hematocrit: Levels DECREASE
Urine Specific Gravity: DECREASE
Serum Protein: May Decrease
BUN: Decreases
May do Chest X-Ray to see if pulmonary fluid excess
Labs indicate a decrease in the serum osmolality and serum Na+ levels. Identify the fluid imbalance. Identify the system failure cause the imbalance.
FVE
Renal Failure
Excessive water retention causing diluation of serum sodium and serum osmolality
Identify the type of diuretic used in the treatment of severe HYPERvolemia. Give an example. How do they work? Which body is monitored?
Loop Diuretic; furosemide, bumetanide, torsemide
Block the reabsorption of sodium in loop of Henle
Kidneys or renal system
Identify 3 electrolytes that can be altered when diuretics are used in the treatment of fluid volume excess. What imbalances may result?
Sodium, Potassium, Magnesium
Hyponatremia, Hypo or Hyperkalemia, Hypomagnesemia
Some community drinking water is too high in sodium for clients on a sodium restriction for treatment of FVE. Is bottled water an acceptable alternative to tap water for these clients.
Check label on bottled water for Na+ content, as Na+ levels in bottled water may vary
Identify client teaching for the client predisposed to FVE. (CHF, Cirrhosis, CRF)
Monitor weight, I&O's, Na+ and fluid intake, following medication schedule (diuretics)
Since Edema is a common sign/symptom of FVE this client must be aware of medications that could cause edema. Identify 2 types of medications the nurse should teach the client to avoid
NSAID's, estrogens, corticosteroids, antihypertensives, OTC medications
Related Nursing DX and Goals for FVE
Fluid Volume Excess
Risk for Impaired Skin Intergrity
Impaired Gas Exchange
Deficient Knowledge
Fluid Volume Excess (Identifed Problem)
Goal
The client will have body fluid levels restored to WNL on/by (time frame)
Fluid Volume Excess AEB
B/P, pulse, respirations WNL
Clear breath sounds on ausculation
Absense of dyspnea and edema
Urine Specific gravity WNL >1.010
Risk for Impaired Skin Intergrity
Goal
The client will maintain skin intergrity on/by (time frame)
Risk for Impaired Skin Intergrity AEB
Absence of reddened pressure areas
Skin pink, warm, and dry centrally an peripherally
Impaired Gas Exchange
Goal
The client will maintain adequate gas exhange on/by (time frame)
Impaired Gas Exchange AEB
Clear breath sounds on auscultation
Absence of dyspnea
Respirations WNL
ABG's WNL
Deficient Knowledge
Goal
The client will verbalize / demostrate an understanding of:
Amount and type of fluids to take each day
Methods to decrease edema
Methods to decrease Na+ intake
Methods to protect edematous skin
S/S to monitor =FVE
on time frame
Deficient Knowledge AEB
will be specific to deficit
Evaluation of Nursing care in Client with FVE
The client should have:
Fluid balance restored
Supportive care provided
Adequate teaching provided
Name 4 organs primary response for regular fluid output
Kidneys, lungs, skin, GI system
What general rule used for approx urinating urinary output for average adult
1 ml of urine/kg/hr
Direction of normal fluid movement within the ECF compartments depends on the difference of what 2 opposing forces
Hydrostatic and osmotic pressure
Aging is accompanied by a decrease in cardiac reserve and in renal function what 2 conditions result in elderly client when excess amounts of IV fluids are rapidly infused even over a short period of time
Fluid overload, cardiac failure
Oliguria, concentrated urine, weak rapid pulse, cool, clammy pale skin, cap refill > 3 sec these are manifestations of which fluid imbalance. Name 3 more
FVD
Poor skin tugor, hypotension, tachcardia
Vomiting, Diarrhea, sweating, 3rd spacing of fluids, diabetes insipidus above cause for which type of fluid imbalance? Additional cause
FVD
Burns
Wound Healing
Identify the complication that develops with rapid fluid volume loss
Hypovolemic shock