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ATI chapter 43: Fluid Imbalances
Terms in this set (48)
It is maintained when the characteristics of body fluid remain in balance: volume, concentration (osmolality), composition (electrolyte concentration), and acidity (pH).
What is the body fluid percentage in a healthy adult?
How does fluid move between compartments?
Through selectively permeable membranes by a variety of methods (diffusion, active transport, filtration, osmosis) to maintain homeostasis.
What is diffusion?
Passive movement of electrolytes and other particles from higher concentration to lower concentration gradient.
What is active transport?
It requires energy, (ATP), to move electrolytes against the concentration gradient into the cell membrane.
What is filtration?
It is the movement of fluids across the capillaries.
What is osmosis?
The pulling of water into and out of the cells by osmotic pressure.
How is balance maintained?
Through input and output.
How is intake regulated?
Not only by thirst, but social and habit play a role in adequate fluid intake.
How is output occur?
It occurs in all the of the following organs, the kidneys, skin, lungs, and GI tract.
What is the major regulator of fluid output?
Two thirds of body water
Body fluids within the cell
One third of body water
Body fluids outside of the cell membrane
Further divided into parts
The liquid part of blood or the plasma
Located between the cells and outside of the blood vessels
Transcellular body fluids
Secreted by epithelial cells (cerebrospinal, pleural, peritoneal, and synovial fluids)
Causes of volume imbalances: Abnormal GI loses
Vomiting, nasogastric suctioning, and diarrhea
Causes of volume imbalances: Abnormal skin losses
Causes of volume imbalances: Abnormal renal losses
Diuretic therapy, diabetes insipidus, kidney disease, adrenal insufficiency, and osmotic diuresis
Causes of volume imbalances: Third spacing
Peritonitis, intestinal obstruction, ascites, and burns
Causes of volume imbalances:
Causes of volume imbalances: Altered intake
Such as nothing by mouth (NPO)
Fluid volume deficits
Can be divided into two main categories: volume imbalances and osmolality imbalances. When there is an issue with volume imbalance, it relates to a lack of body fluid in the extracellular compartment. Osmolality imbalances occur when there is disturbance in concentration of body fluid.
When does osmolality imbalances occur?
When body fluid becomes either hypertonic or hypotonic.
Ex: hypernatremia (water deficit)
Ex: Hyponatremia (water excess or intoxication)
Risk factors of Fluid loss
-Increased intake of caffeine and alcohol
-living at high elevations or in dry climates
-the effect of fluid imbalance in older adults is greater due to the loss of elasticity of the skin, decrease in glomerular filtration and concentrating ability of the kidneys, loss of muscle mass (muscle tissue holds more body water) and diminished thirst reflex
Expected findings of Hypovalemia
Vitals: hyperthermia, tachycardia (in an attempt to maintain a normal blood pressure), thready pulse, hypotension, orthastatic hypotension, decreased central venous pressure, tachypnea (increased respirations to compensate for lack of fluid volume within the body), hypoxia
Neuromusculoskeletal: dizziness, syncope, confusion, weakness, and fatigue
GI: Thirst, dry furrowed tongue, nausea, vomitting, anorexia, and actual weight loss
Renal: Oliguria (decreased production and concentration of urine)
Other findings: diminsehd capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins, poor skin turgor and tenting, weight loss, low central venous pressure
Expected Findings of osmolality imbalances or hypernatremia
-Skin that is dry and flushed
-Restlessness, confusion, agitation
-Coma and seizures can occur because onset of fluid imbalance is rapid
Laboratory tests: Hct
increased in hypovalemia
laboratory tests: BUN
increased (greater 25 mg/dL) due to hemoconcentration
Laboratory tests: Urine specific gravity
Greater than 1.030
Laboratory tests: Serum sodium
Greater than 145 mEq/L
Laboratory tests: Serum osmolality
Greater than 295 mOsm/kg
Nursing care for fluid volume deficits
-Monitor Vitals. Orthostatic measurements should be assessed as a client is at increased risk of falls when orthostatic hypotension present.
-Monitor for changes in mentation and confusion (an indication of worsening fluid imbalance). Administer IV hydration as prescribed.
-Monitor weight every 8hr while fluid replacement in progress
-Assess level of gait stability. Encourage the client to use call light and ask for assistance.
-Initiate fall precautions
-Encourage the client to change positions, rolling from side to side or standing up slowly.
Interprofessional care for fluid volume deficits
The nurse should collaborate with other members of the health care team to determine appropriate fluid volume replacement and oxygen management.
Client education for fluid volume deficits
-Encourage the client to drink plenty of liquids to promote hydration
-Educate the client regarding causes of dehydration, such as nausea and vomiting.
Complications with fluid volume deficits
-the clients mean arterial pressure decreases (which slows blood flow and perfusion to tissues of the body and the cells are no longer able to carry oxygen to the blood adequately (due to loss of red blood cells)
Nursing actions for patients experiencing fluid volume deficit
-administer oxygen and monitor oxygen saturation. Oxygen saturation less than 70% is a medical emergency.
-stay with an unstable client suffering from hypovolemic shock
-monitor vitals every 15 mins
-Provide fluid replacement with the following
colloids: whole blood, packed RBCs, plasma, synthetic plasma expanders
Crystalloids: lactated Ringer's, normal saline
-Administer vasoconstrictors (dopamine, norepinephrine, phenylephrine), agents to improve myocardial perfusion (sodium nitroprusside), and/or positive inotropic medications (dobutamine, milrinone)
-perform hemodynamic monitoring
Fluid volume excesses
Clinical indication that the intake of fluids and the excretion of fluids is not in balance. Another term for this phenomenon is hypervolemia, as there is excess fluid in the extracellular space.
-can also occur when the electrolytes in the body are not in balance.
-Clients who experience this are at risk for developing pulmonary edema or congestive heart failure
Health promotion and disease prevention for fluid volume excess
In healthy people, the body will compensate for slight changes in fluid imbalance and the excessive intake of electrolytes. In the elderly population, the risk of fluid imbalance is greater due to changes in the body with age (reduced kidney function)
-When clients have known heart disease and impairment of kidney function, its important for the nurse to instruct the client regarding the following
-consume a diet low in sodium. Consult with the provider regarding diet restrictions.
- Restrict fluid intake. COnsult with provider regarding prescribed restrictions.
Causes of hypervolemia
-Clients who have compromised regulatory systems, such as heart failure, kidney disease, and cirrhosis
-overdose of sodium concentrated fluids
-fluid shifts that occur following burns
-prolonged use of corticosteroids
Expected findings: Fluid volume overload
Vitals: Tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure
Neuromuscular: Weakness due to excess fluid retained, which depletes energy and increases the workload for the body; headache altered level of consciousness
Respiratory: Crackles, cough, increased respiratory rate, dyspnea caused from an excess of fluids within the body and lungs.
Other signs: Peripheral edema due to an excess of fluids within the body and lungs, resulting in weight gain, distended neck veins, and increased urine output.
Laboratory tests for fluid volume excesses
-Decreased Hct and Hgb
-Decreased serum and urine osmolarlity
-Decreased urine sodium and specific gravity
-Decreased BUN due to plasma dilution
Diagnostic procedures for fluid volume excesses
Chest x ray: reveals possible pulmonary congestion
Patient centered care for fluid volume excesses
-monitor I&O, daily weight, peripheral edema, receiving diuretics serum sodium and potassium levels
-Assess breath sounds
-Maintain sodium-restricted diet
-Maintain fluid restrictions
-Encourage the client to discuss the use of over-the counter medications with the provider, as some of these contain sodium
-Position the client in semi-fowlers postion and reposition to prevent tissue breakdown in edematous skin
-Use a pressure-reducing mattress, and assess bony prominence on a regular basis
Interprofessional care for Fluid volume excess
-respiratory services may be consulted for oxygen management
-pulmonology may be consulted if fluid moves into lungs
Client education for fluid volume excess
-Encourage client to weigh himself daily. Notify the provider if there is 1- to 2 lb gain in 24 hr, or a 3 lb gain in 1 week. After the first 1/2 lb weight gain, each additional pound of weight gain is equal to 500 mL retained fluid
-Instruct the client to consume a low-sodium diet, read food labels to check sodium content and keep a record of daily sodium intake
-Promote fluid restriction intake. COnsult with the provider regarding prescribed restrictions
Complications with pulmonary edema
-Can be caused by severe fluid overload
-manifestations include anxiety, tachycardia, increased vein distention, premature ventricular contractions dyspnea at rest, change in level of consciousness, restlessness, lethargy, ascending crackles (fluid level within lungs) and cough productive of frothy pink-tinged sputum
Nursing actions for pulmonary edema
-position the client in high-fowlers to maximize ventilation
-Administer oxygen, positive airway pressure, and/or possible intubation and mechanical ventilation
-Administer morphine, nitrates, and diuretic as prescribed if blood pressure is adequate.
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