FLUID VOLUME DISTRUBANCES (WEEK 2) - third-space fluid shifts, or the movement of fluid from the vascular

 Hypovolemia system to other body spaces (eg, with edema formation in burns,
 Hypervolemia ascites with liver dysfunction).

HYPOVOLEMIA Pathophysiology
Fluid Volume Deficit (FVD)
- loss of ECF volume exceeds the intake of fluid  Diabetes insipidus
- ECF loss is greater than the fluid intake. It occurs when water - decreased ability to concentrate urine interferes with water
and electrolytes are lost in the same proportion as they exist in reabsorption
normal body fluids, so that the ratio of serum electrolytes to water - Additional causes include diabetes insipidus (a decreased ability
remains the same. to concentrate urine OWING TO A DEFECT IN THE KIDNEY
- different from dehydration TUBULES that interferes with water reabsorption),
- FVD (hypovolemia) should not be confused with DEHYDRATION,  Polyuria – frequent urination
which refers to loss of water alone, with increased serum sodium  Polydipsia – excessive thirst
levels.
- FVD may occur alone or in combination with other imbalances.  Adrenal insufficiency - impaired production of aldosterone
- Adrenal glands do not produce enough amount of steroid
Pathophysiology hormones (primarily cortisol)
- Cortisol can help control blood sugar levels, regulate metabolism,
 loss of body fluids + ↓ fluid intake help reduce inflammation, and assist with memory formulation.
- FVD results from loss of body fluids and occurs more rapidly - It has a controlling effect on salt and water balance and helps
when coupled with decreased fluid intake. control blood pressure and may also include impaired production
- FVD can also develop with a prolonged period of inadequate of aldosterone which is also important on water and Na
intake. reabsorption and increasing the blood volume thus, increasing
 abnormal fluid losses urination.
 vomiting
 diarrhea  Osmotic diuresis - increase in urine output
 GI suctioning - Osmotic diuresis is the increase in urine output caused by the
 Sweating excretion of substances (electrolytes) such as glucose, mannitol,
- FVD may also be a cause of abnormal fluid losses or contrast agents in the urine.
such as those resulting from vomiting, diarrhea, GI suctioning, and
sweating;  Hemorrhage
- abnormal fluid losses - ↓ circulating blood volume
 nausea
 lack of access to fluids
 third – space fluid shifts
- decreased intake, as in nausea or lack of access to fluids;  Coma
- Recent studies have reported that fluid and electrolyte Clinical S/Sx
imbalances are associated with increased morbidity and mortality - Clinical S/Sx of HYPOVOLEMIA
among critically ill patients. - FVD can develop rapidly, and its severity depends on the degree
- Development of hyponatremia in critically ill patients is associated of fluid loss.
with disturbances in the renal mechanism of urinary dilution. - Contributing Factors:
- Hypernatremia is associated with cellular dehydration and central  vomiting,
nervous system damage.  diarrhea,
 fever,
- Fluid and electrolyte disorders are among the most common  Fistulas,
clinical problems encountered in the setting of intensive care. -  Sweating,
Critical disorders such as severe burns, trauma, sepsis, brain  Burns
damage, and heart failure lead to disturbances in fluid and  Blood loss
electrolyte homeostasis. Possible mechanisms include reduced  GI suctioning
perfusion to the kidney due to hypovolemia or hypotension;  3rd - space fluid shifts
activation of hormonal systems such as renin-angiotensin-  Anorexia
aldosterone system and vasopressin; and tubular damage caused  Nausea
by ischemic or nephrotoxic kidney damage, including renal insult  Inability to gain access to fluid
caused by a myriad of medications used in the intensive care. In  Diabetes insipidus
addition, inappropriate administration of fluid and electrolytes  Uncontrolled diabetes
should be considered in the diagnosis and treatment of fluid and FISTULA
electrolyte disturbances. - A gastrointestinal fistula (GIF) is an abnormal opening in your
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043756/ digestive tract that causes gastric fluids to seep through the lining
of your stomach or intestines. This can result in infection when
 Low Fluid Volume these fluids leak into your skin or other organs
 Urination BURNS
 Reabsorption - Severe burns causes third-space fluid shift due to increased
 ECF loss capillary permeability.
- So in short, hypovolemia occurs when a person has INABILITY TO GAIN ACCESS TO FLUID
Low fluid volume in the blood (Hypo – vol – emia) - Remote areas where there is a difficulty in accessing proper
 Frequent urination (↓GFR) water supply
 Impaired water and - African countries, where people dies of diarrhea (that is why Bill
 Na reabsorption (kidney problems, ADH and aldosterone gates focuses himself in contributing how he can provide the
malfunctions) people of appropriate water supply from their feces)
 ECF loss is greater than the fluid intake DIABETES INSIPIDUS, UNCONTROLLED DIABETES
- Both contribute to a depletion of ECF (polyuria, polydipsia)
Assessment and Diagnostic Findings Signs and Symptoms
 Acute weight loss
 ↓ skin turgor - The central venous pressure (CVP) is the pressure measured
 Oliguria in the central veins close to the heart. It indicates mean right atrial
- Early symptoms of hypovolemia include headache, fatigue, pressure and is frequently used as an estimate of right ventricular
weakness, thirst, and dizziness (and urination). preload. the initial stretching of the muscle cells prior to contraction
- The more SEVERE SIGNS AND SYMPTOMS are often (before it is ejected). the filling pressure of the heart at the end of
associated with hypovolemic shock. diastole.
- These include oliguria, cyanosis, abdominal and chest pain, - The left atrial pressure (LAP) at the end of diastole will
hypotension, tachycardia, cold hands and feet, and progressively determine the preload. It is related to ventricular filling. The CVP
altering mental status. does not measure blood volume directly, although it is often used
to estimate this. Low CVP may indicate hypovolaemia. Decreased
 Concentrated urine blood volume affects CVP and preload
- Causes of oliguria include decreased renal blood flow, renal
insufficiency, and urinary outflow obstruction.  ↓ BP
- Because of ECF loss… - ↓ BP indicates ↓ blood volume
Hypovolemia is compensated or partially compensated for by - ↓ blood volume affects arterial pressure
the body preserves what is left off of the remaining water
increasing the heart rate, concentrating the urine, and  flattened neck veins
decreasing urine output.  - Jugular veins
- Sign of ↓ intravascular volume
 Capillary filling time prolonged - Little blood volume is circulating
- Capillary refill on the nail beds (blanch test) It is used to - Severe signs of hypovolemic shock
monitor FVD (dehydration) and the amount of blood flow to tissue.
If there is good blood flow to the nail bed, a pink color should  dizziness
return in less than 2 seconds after pressure is removed. A  Weakness
prolonged capillary refill time may be a sign of shock (hypovolemic - Early s/sx of hypovolemia
shock) and can also indicate dehydration and decreased
peripheral perfusion.   thirst and confusion
- Thirst are early s/sx of hypovolemia
 ↓ CVP - Confusion early signs and symptoms of hypovolemic shock
- Capillary refill on the nail beds (blanch test) It is used to
monitor FVD (dehydration) and the amount of blood flow to tissue.  ↑ pulse
If there is good blood flow to the nail bed, a pink color should - A narrow pulse pressure in a hypovolemic shock patient indicates
return in less than 2 seconds after pressure is removed. A a decreasing cardiac output and an increasing peripheral vascular
prolonged capillary refill time may be a sign of shock (hypovolemic resistance.
shock) and can also indicate dehydration and decreased - The decreasing venous volume from blood loss and the
peripheral perfusion.  sympathetic nervous system attempt to increase or maintain the
falling blood pressure through systemic vasoconstriction. The body - Serum osmolality primarily reflects the concentration of Na, BUN
compensates. and glucose in the blood (as previously discussed)
Because water is lost, those solute or electrolytes will tend to
 muscle cramps increase by amount
- FVD may also include losses and imbalances of electrolytes
(especially K)  urine osmolality ↑
- K, Na, P, glucose - Urine osmolality is determined by the concentration of urea,
creatinine and uric acid (all waste) Because water is lost,
 sunken eyes increased concentration of the mentioned wastes. Because the
- Traditional signs of hypovolemia that also includes kidneys try to compensate by conserving water. Question.. The
Dry mucus membranes most reliable indicator to determine concentration of waste is???
-↓ skin turgor Answer… urine osmolality

 nausea  specific gravity ↑

- Due to loss of Na and water, ↓ blood volume as a severe sign - Urine-specific gravity (USG) measures the kidney’s ability to
and symptom excrete and conserve water
- Because water is lost, kidneys tends to decrease the excretion of
 ↑ temperature water (measures the presence of solute concentrations, but….)
- May also be a latent sign of hypovolemic shock or maybe even - USG is increased in relation to the kidneys attempt to conserve
during fever, the body compensates by decreasing the urine output water
thus water are reabsorbed to maintain the balance - USG less reliable indicator of concentration
- Varies inversely with urine volume, larger volume or urine – lower
 cool, clammy, pale skin USG
- Cold, clammy skin as a result of sweating - Factors that increase or decrease the urine osmolality are the
- Pale skin due to decreased circulation of blood to tissues same as those for USG
(capillary refill)
 urine Na ↑
LABORATORY FINDINGS - ↓ reading of sodium in the urine because it is what is only left in
 Hgb and Hct ↑ the ECF due to water loss
- Increase or decrease? - There is a ↓ excretion of Na in the urine
Due to hemoconcentration - Low urinary sodium is commonly found in hypovolemic patients
↓ plasma volume (↓ water in the plasma) as the kidneys attempt to conserve sodium and water to expand
the extracellular volume

 BUN and Creatinine ↑

 serum osmolality ↑ - Normal BUN to serum Creatinine concentration ratio is 10:1
- A volume depleted patient has a BUN elevated out of proportion
the serum Creatinine (ratio greater than 20:1)
- Both waste products due to ↓ water in the urine, as a result both
waste products reading will be elevated
- Question.. If you want to consider fluid volume deficit, what will
you take note of?
- Answer… BUN (because it is the result of protein metabolism (as
from dietary intake)
- Question… if you want to consider renal function, what will you
take note of?
- Answer… Creatinine (because it is the result of muscle
metabolism, dietary intake is not a factor in Creatinine)
GERONTOLOGIC CONSIDERATIONS
- Increased sensitivity to fluid and electrolyte changes in elderly
patients requires careful assessment
 I & O from all sources
- Oral, parenteral, transfusions, feces, urine, vomitus, sweats,
bleeding.
 Daily weight
- assessment of changes in daily weight
- Normally taken every morning
 SE of medications
- careful monitoring of side effects and interactions of medications
- Medications may affect fluid balance especially older adults
because of cardiac, renal abnormalities brought by aging.
 documentation and prompt reporting
- prompt reporting and management of disturbances
Prompt – because no matter how many patients you are handling,
any changes may result to irreversible abnormalities, that your
rapid, proper and appropriate reporting is necessary
 skin turgor
- In most adult patients, it is useful to monitor skin turgor serially to
detect subtle (progressive, unexpected) changes.
However, assessment of skin turgor IS NOT AS VALID IN THE
ELDERLY because the skin has lost some of its elasticity;
therefore, other assessment measures (eg, slowness in filling of
veins of the hands and feet – capillary refill) become more useful in
detecting FVD (Cash & Glass.
 Functional Assessment
- The nurse also performs a functional assessment of the
ability of the elderly patient to determine fluid and food needs and
to obtain adequate intake
- For example, is the patient cognitively intact, able to ambulate
and to use both arms and hands to reach fluids and foods, and
able to swallow?
nurse provides if the patient is unable to carry out self-care
activities
- Results of this assessment have a direct bearing on how the
patient will be able to meet his or her own need for fluids and foods
(functional assessment)
During an older patient’s hospital stay, the nurse provides fluids if
the patient is unable to carry out self-care activities (if the patient
cannot drink or eat) Category 2 patient classification system
 incontinence
- The nurse should also recognize that some older patients
deliberately restrict their fluid intake to avoid embarrassing
episodes of incontinence.
 wear diapers
 urinal
 pace fluid intake
 remind to drink adequate fluids
- Older adults without cardiovascular or renal dysfunction should
be reminded to drink adequate fluids, particularly in very warm or
humid weather.
MEDICAL MANAGEMENT
 Correction of Fluid Loss
- When planning the correction of fluid loss for the patient with
FVD, the primary health care provider considers the patient’s
maintenance requirements of the patient and other factors (eg,
fever) that can influence fluid needs.
- Physicians’ treatment of the fluid loss will base on the client’s
health status based on the correct and efficient assessment of the
nurse
 oral route - If the deficit is not severe, the oral route is
preferred, provided the patient can drink.
 IV route - However, if fluid losses are acute or severe,
the IV route is required. Again, remember that the
necessity to hook to an IV therapy is based on their
health status. How it will address the fluid loss? Is it
necessary? So, consider some factors that would put
your patient into IVT.
 isotonic electrolyte solutions
 lactated Ringer’s
 0.9% NaCl
- Isotonic electrolyte solutions (eg, lactated Ringer’s
solution, 0.9% sodium chloride) are Frequently the first
line of choice TO TREAT THE HYPOTENSIVE
PATIENT with FVD because they expand plasma
volume.
- If there will immediate changes on the client’s health
status (ie. diagnostics confirms assessment), changes
in fluid management is also imminent
 0.45% NaCl
Hypotonic
- As soon as the patient becomes normotensive
(normal BP), a hypotonic electrolyte solution (eg,
0.45% sodium chloride) is often used to provide both
electrolytes and water for renal excretion of metabolic
wastes.
- Half-strength saline
 Strict Monitoring
 I &O - Accurate and frequent assessments of I&O
- Determines fluid volume status of the body
- monitor patients who have fluid imbalances or are at high risk of
dehydration by calculating intake and output (I&O) each shift
- keep an accurate record of a patient's fluid input and output and
to identify any deficits
- Fluid balance chart, I&O record
 Weight - The response of the body in hypovolemia is
weight loss. Expect a physician would order weight
monitoring.
 Vital Signs - So why would the physician would order
VS monitoring??
- It is very important to know every changes in the VS
so that we will what to treat and manage because
nursing interventions are dictated by what is our
treatment goal
 CVP - Some physicians orders central lines for
patients with severe hypovolemia
 LOC - Mental status is also a determinant of sever
hypovolemia because the brain can receive little of no
brain perfusion due to decrease blood volume
circulating to major organs of the body
 Breath Sounds - RR is also compensated during
hypovolemia (eg. ↑ RR) With severe hypovolemia and
not treated may lead to respiratory failure. We must be
aware of the abnormal sounds present during
respiratory failure (eg. Cracklings)
 Skin Color - Skin color are affected because the body
compensates by diverting blood away fro non-vital
organs (skin is one of them) and moves towards major
organs. Pallor
 treatment is based on the severity of fluid loss -
The rate of fluid administration is based on the severity
of loss and the patient’s hemodynamic response to
 volume replacement (Sterns, 2014). As well as our
nursing interventions!
 Renal Function
 determine the cause of depressed renal function
 prerenal azotemia
- If the patient with severe FVD is not excreting enough
urine and is therefore oliguric, the primary health care
provider needs to determine whether the depressed renal
function is caused by
prerenal azotemia
- reduced renal blood flow secondary to FVD
elevations in BUN and creatinine levels resulting from
problems in the systemic circulation that decrease flow to
the kidneys
 Acute tubular necrosis
- or, more seriously, by acute tubular necrosis from
prolonged FVD.
- Death of renal tubule cells of the kidneys
- Should be determined so that doctors and nurses will
perform the correct interventions
- Because different clinical manifestations presented on
reduced renal blood flow secondary to FVD and acute
tubular necrosis from prolonged FVD
 Fluid challenge test
- The test used in this situation is referred to as a fluid
challenge test.
During a fluid challenge test, volumes of fluid are
administered at specific rates and intervals while the
patient’s hemodynamic response to this treatment is
monitored.
 vital signs
 breath sounds
 sensorium
 CVP
 UO
- That is.. Because the changes in these following responses are
the determinants of FVD due to decrease blood volume and NOT
RELATED TO TUBULAR NECROSIS!
- 100 to 200 mL of normal saline solution over 15 minutes (fluid
challenge test) an example of a typical fluid challenge involves
administering 100 to 200 mL of normal saline solution over 15
minutes.
- provide fluids rapidly enough to attain adequate tissue perfusion.
The goal is to provide fluids rapidly enough to attain adequate
tissue perfusion without compromising the cardiovascular system
(cardiac overload).
- ↑ UO, ↑ BP, ↑ CVP. The response by a patient with FVD but
normal renal function is increased urine output and an increase in
blood pressure and central venous pressure.
 Shock
 25% intravascular volume loss or rapid fluid volume
loss
- (Hypovolemic) Shock can occur when the volume of fluid lost
exceeds 25% of the intravascular volume, or when fluid loss is
rapid. Shock discussed later discussions..
NURSING MANAGEMENT
 Intake and Output
 q8 or q1
- To assess for FVD, the nurse monitors and measures fluid
I&O at least every 8 hours, and sometimes hourly.
- Every 8 commonly ordered for routine I&O monitoring and
stable patients
- Every 1 hour is done for critical patients eg. Post op,
hypovolemia
 may impact the mortality of patients
- Researchers have reported that maintaining an accurate I&O
is a particular challenge with patients in critical care settings
(Diacon & Bell, 2014) – see chart
- A research identified that I&O was not being accurately
measured in the critically ill patients in the ICUs studied.
 - It is imperative that accurate calculations of fluid balance be
an integral part of nursing practice in the ICU setting.
- Regular outcome-driven audits may help improve practice
and thus impact the mortality of patients IN THE ICU
SETTING.
 expect a concentrated urine
< 30mL/hr
- As FVD develops, body fluid losses exceed fluid intake
through excessive urination (polyuria), diarrhea, vomiting, or
other mechanisms.
- Once FVD has developed, the kidneys attempt to conserve
body fluids, leading to a urine output of less than 30 mL/h in an
adult.
- A ↓ UO can be observed because ADH and aldosterone (as a
compensatory mechanism) has been produced for water to be
absorbed. Urine in this instance is concentrated and
represents a healthy renal response.
 Daily body weight
0.5kg weight loss is approximately 500ml fluid loss
- Daily body weights are monitored; an acute loss of 0.5 kg (1
lb) represents a fluid loss of approximately 500 mL.
(One liter of fluid weighs approximately 1 kg, or 2.2 lb.)
 Vital Signs
 Closely monitored
- Vital signs are closely monitored.
- Because vital signs will be significantly abnormal once the
body cannot anymore compensate with the severity of the loss.
- Compensatory mechanism will fail!
 Tachycardia - Note for Tachycardia – because the
body has declined supplying blood (due to the fluid
loss) to the heart and thereby compensates by
vasoconstriction delivering blood to the heart to
increase the stroke volume thus increasing cardiac
output thus increasing tissue perfusion to vital
organs
 Severe hypotension - the body will at first
respond to the vasoconstriction, ADH and
aldosterone release causing the BP to increase
regardless of the fluid loss. But then will be
significantly decreased because of severe fluid
loss which the body cannot compensate anymore
due to decreased cardiac output.
 Tachypnea - the body compensates by ↑ the RR
due to ↓ lung tissue perfusion caused by ↓ CO
thereby oxygen delivery to tissues. Intubation and
hooking the patient to mechanical ventilation if
necessary.
 ↓ Peripheral pulses - shifting blood away from the
extremities towards vital organs. Decreased
peripheral perfusion can also result in cold
extremities. So you must be careful in your
assessment!
 ↓ Temperature - A decrease in body temperature
often accompanies FVD, unless there is a
concurrent infection.
 ↓ CVP - if patient is with central line, note for the
decline due to decreasing blood volume of the
heart. In patients with relatively normal
cardiopulmonary function, a low central venous
pressure is indicative of hypovolemia.
 Skin
 Skin and tongue turgor
 Pinch Skin - Skin and tongue turgor are monitored on
a regular basis. A good determinant of FVD. In a
healthy person, pinched skin immediately returns to its
normal position when released (Weber & Kelley,
2014). You may also include to assess the
temperature thru palpation on the skin.
Generally, skin feels warm and moist with early signs of
hypovolemia
  Dependent on interstitial fluid volume - This elastic
property, referred to as turgor, is aside from its elastic
property, turgor is partially dependent on interstitial
fluid volume (available fluid volume in the body)
 skin flattens more slowly - In a person with FVD,
(early signs of hypovolemia) the skin flattens more
slowly after the pinch is released. The skin still feels
warm to touch
 remain elevated for many seconds - In a person with
severe FVD, (signs of hypovolemic shock) the skin
may remain elevated for many seconds. The skin feels
cool and clammy upon palpation. Because the blood is
diverted away from non-vital organs (skin is one of
them).
 over the sternum, inner aspects of the thighs,
forehead - Tissue turgor is best measured by pinching
the skin over the sternum, inner aspects of the thighs,
or forehead, because these areas maintain better skin
turgor than other areas. Areas that will give you a good
approximation of FVD assessment
 tongue turgor is not affected by age - Tongue turgor
is not affected by age (see previous Gerontologic
Considerations), and evaluating this may be more valid
than evaluating skin turgor. Eg. Evaluating turgor of
older adults on their skin may only mean a ↓ elasticity
rather than FVD
 smaller tongue, longitudinal furrows - In a normal
person, the tongue has one longitudinal furrow.
Fissures, deep and prominent grove in the middle of
the tongue. In the person with FVD, there are
additional longitudinal furrows and the tongue is
smaller, because of fluid loss.
 Dry Mouth
- The degree of oral mucous membrane moisture is also assessed;
a dry mouth may indicate either FVD or mouth breathing.
 Urine Specific Gravity
 >1.020
 healthy renal conservation of fluid - Urine
concentration is monitored by measuring the urine
specific gravity. In a volume-depleted patient, the urine
specific gravity should be greater than 1.020, indicating
healthy renal conservation of fluid. Due to water
absorption of the kidneys as a result of ADH
production. But will increase more in severe FVD
accompanied by OLIGURIA. A UO less than normal.
The normal range of urine output is 800 to 2,000
milliliters per day if you have a normal fluid intake of
about 2 liters per day.
 Mental Function
 ↓ cerebral perfusion
- Mental function is eventually affected in severe FVD as a
result of decreasing cerebral perfusion.
- ↓ tissue perfusion in the brain (↓ blood flow to the brain)
 mild anxiety, confusion and agitation, comatose -
From mild anxiety in early signs of hypovolemia to
Confusion and agitation in severe signs of
hypovolemia to being comatose in shock
 Hemodynamic
- Hemodynamics are dynamics of blood flow that controls the
homeostasis (balance)
 acute cardiopulmonary decompensation - a
combination of symptoms and signs that indicate that the
heart by reason of its abnormal condition no longer is able
to maintain an efficient circulation. Patients with acute
cardiopulmonary decompensation require more extensive
hemodynamic monitoring of pressures in both sides of the
heart to determine if hypovolemia exists. To determine,
note for:
 CVP – if necessary
 Peripheral pulses
 HR
 BP
PREVENTING HYPOVOLEMIA
- identify patients at risk and take measures to minimize fluid
losses
- To prevent FVD, the nurse identifies patients at risk and takes
measures to minimize fluid losses.
- For example, if the patient has diarrhea, measures should be
implemented to control diarrhea and replacement fluids given.
- This includes administering antidiarrheal medications and small
volumes of oral fluids at frequent intervals.
- Take note! We have to establish treatment goals first because it
will dictate what will be our nursing interventions
Eg. ↑ Venous return – ↑ cardiac preload – ↑ stroke volume – ↑
cardiac output – ↑ tissue perfusion
CORRECTING HYPOVOLEMIA
 Oral Fluids
- When possible, oral fluids are administered to help correct FVD,
with consideration given to the patient’s likes and dislikes.
If the patient is reluctant to drink because of oral discomfort, the
nurse assists with frequent mouth care and provides nonirritating
fluids.
- water only
- The type of fluid the patient has lost is also considered and fluids
most likely to replace the lost electrolytes are appropriate.
 Oral Rehydration Solutions
- The patient may be offered small volumes of oral
rehydration solutions (eg, Rehydralyte, Elete, Cytomax).
These solutions provide fluid, glucose, and electrolytes in
concentrations that are easily absorbed.
 Oresol
 Gatorade
 Antiemetics
- If nausea is present, antiemetics may be needed before oral
fluid replacement can be tolerated.
 Metoclopranide (plasil)
 Ranitidine
 Parenteral
 Isotonic - If the deficit cannot be corrected by oral fluids,
therapy may need to be initiated by an alternative route
(enteral or parenteral) until adequate circulating blood
volume and renal perfusion are achieved. Isotonic fluids
are prescribed to increase ECF volume (Sterns, 2014).
 Enteral
- Enteral feeding via the GI tract, NGT, OGT
HYPERVOLEMIA
 Fluid Volume Excess (FVE)
 Isotonic Expansion of the ECF - refers to an isotonic
expansion of the ECF. caused by the abnormal retention of
water and sodium in approximately the same proportions
(twice the normal amount) in which they normally exist in
the ECF. Particularly intravascular spaces / third – spacing
(interstitial spaces) because there is isotonic retention of
body substances, the serum sodium concentration remains
essentially normal.
 ↑ in total body water - It is most often secondary to an
increase in the total body sodium content, (build – up and
retention of fluid) which, in turn, leads to an increase in
total body water.
PATHOPHYSIOLOGY
 ↓ function of the homeostatic mechanisms responsible for
regulating fluid balance
- FVE may be related to simple fluid overload or diminished
function of the homeostatic mechanisms responsible for regulating
fluid balance.
 Heart Failure - Due to the inability of the heart to circulate
the fluid properly causing a build – up of fluid
 Renal Failure - Due to the inability of the kidneys to filter
blood again causing build – up of fluid due to water and Na
retention
  cirrhosis of the liver - Liver failure (2 ways) Caused by
the affected liver sending signals to kidneys to retain
excess Na and water which accumulates in the tissues,
thereby increasing the volume. The liver’s inability to
produce enough of the protein albumin which is the main
protein in the blood that maintains stable blood volume
 consumption of excessive amounts of salts - Another
contributing factor is consumption of excessive amounts of
table or other sodium salts.
 consumption of excessive amounts of salts excessive
administration of sodium – containing fluids -
Excessive administration of sodium-containing fluids in a
patient with impaired regulatory mechanisms may
predispose him or her to a serious FVE as well.
ASSESSMENT AND DIAGNOSTIC FINDINGS
CLINICAL S/SX
Contributing Factors
 Kidney injury
 Heart failure
 Liver cirrhosis
 Overzealous administration of Na containing fluids
Contributing Factors
 Fluid shifts (treatment of burns) - Due to increased
permeability of burned tissues, fluid shifts into spaces
particularly interstitial spaces (3rd – spacing)
 Prolonged corticosteroid therapy - Because cortisone is
involved in regulating the body's balance of water, sodium, and
other electrolytes, using these drugs can promote fluid
retention and sometimes cause or worsen high blood pressure.
- All corticosteroid drugs, including prednisone, can cause sodium
retention, resulting in dose-related fluid retention.
- Remember that water follows Na
- Corticosteroids with strong mineralocorticoid effects, such as
fludrocortisone and hydrocortisone, produce the greatest amount
of fluid retention.
- Prednisone causes the body to retain sodium and lose
potassium.
- This combination can result in fluid retention, weight gain, and
bloating.
- Many people are taking prednisone due to an inflammatory or a
chronic condition.
- Steroids are used to treat inflammatory conditions.
- Corticosteroid drugs are used to treat rheumatoid arthritis, lupus,
asthma, allergies and many other conditions.
- They also treat Addison's disease, a condition where the adrenal
glands aren't able to produce even the minimum amount of
corticosteroid that the body needs.
 Severe Stress - Long-term stress can increase the hormone
cortisol, which directly influences fluid retention and water
weight. This may occur because stress and cortisol increase a
hormone that controls water balance in the body, known as the
antidiuretic hormone or ADH. Cortisol can help control blood
sugar levels, regulate metabolism, help reduce inflammation,
and assist with memory formulation. It has a controlling effect
on salt and water balance and helps control blood pressure
 Hyperaldosteronism - Hyperaldosteronism augment
(enhances) fluid volume excess. Hyperaldosteronism is a
disease in which the adrenal gland(s) make too much
aldosterone which leads to hypertension and low blood
potassium levels. Because aldosterone promotes excretion of
K in the urine, too much aldosterone excretes K more than the
normal level caused by either hyperactivity in one or both
adrenal gland and/or idiopathic bilateral adrenal hyperplasia
SIGNS AND SYMPTOMS
 Vital Signs
  Tachycardia - excess fluid can speed up or slow your
heart rate. In this case HR is ↑ because of the effort of the
heart (the heart receives blood higher than the normal
amount) Hypervolemia causes the Na to increase and
water. Na increases HR. As a result, your blood pressure
and heart rate will increase.
 Bounding pulse - As hypervolemia continues, there is a
tendency for fluids to be pushed out of the blood vessels
into the tissues. There is a force present during pulsations
due to increasing blood volume in the heart.
 ↑ BP - High level of sodium, Water retention , Increased
blood volume. As a result, your blood pressure and heart
rate will increase.
 ↑ CVP - CVP is elevated because of overhydration which
increases venous return. JVD is a sign of increased central
venous pressure (CVP). That's a measurement of the
pressure inside the vena cava.
 Respiratory System
 Tachypnea - ↑ in RR in cases of accumulation of fluids in
lung spaces, pulmonary edema, pleural effusion
 shortness of breath - shortness of breath caused by extra
fluid entering your lungs and reducing your ability to
breathe normally. Lungs are being depressed by the extra
fluid. Pulmonary edema. Pleural effusion
 crackles - Pulmonary edema may cause crackling sounds
in your lungs. People with congestive heart failure (CHF)
often have pulmonary edema. CHF occurs when the heart
cannot pump blood effectively. This results in a backup of
blood, which increases blood pressure and causes fluid to
collect in the air sacs in the lungs.
 cough - Pulmonary edema is a condition involving fluid
buildup in the lungs. Sudden onset (acute) pulmonary
edema is a medical emergency. Symptoms include
shortness of breath, cough, decreased exercise tolerance
or chest pain.
 Orthopnea - Difficulty of breathing in lying position. This
condition is caused by too much fluid in the lungs, which
makes it difficult to breathe. The shortness of breath gets
worse when you lie down.
 GI system
 Acute weight gain - Due to retention and build – up of
fluids
 ascites - Due to liver failure, fluids are not properly
excreted by the kidneys causing build – up of fluid in the
abdomen. Liver is responsible in telling the kidneys to
excrete Na and water through the adrenal glands to
produce ADH, responsible in maintaining fluid balance.
 Other s/sx
 Peripheral edema - Fluids seeps out of the intravascular
system and other tissues due to problems occurring from
the systems affecting fluid balance (heart, kidneys, liver).
Fluid seeps out to the extra spaces or interstitial spaces (of
the legs and arms) causing third – spacing. Take note:
 Third – spacing of the lungs – pulmonary
edema
 Third – spacing in the abdomen – ascites
 distended jugular veins - When a patient is fluid-
overloaded, the right heart pressures increase and transmit
back to the jugular vein, causing jugular venous distention.
(Drawing from notes) The vena cava runs to your heart,
where blood arrives before passing through your lungs to
pick up oxygen. JVD is a sign of increased central venous
pressure (CVP). That's a measurement of the pressure
inside the vena cava.The patient needs to be at a 45
degree angle for proper evaluation; gravity lessens JVP if
upright and increases JVP if supine.
 ↑ UO - When recovering from hypervolemia, an increase in
UO will be noted.
 When diuretics is applied as treatment, an increase in UO
will be noted

LABORATORY FINDINGS
 ↓ Hgb and Hct - Both the hemoglobin and the hematocrit are
based on whole blood and are THEREFORE DEPENDENT
ON PLASMA VOLUME. The levels of Hgb and Hct depends on
the plasma volume (the plasma is diluted). So, if the plasma
volume is low (FVD), Hgb and Hct is high (lumapot ang dugi
dahil bumaba ang fluid). If the plasma volume is high (FVE),
Hgb and Hct is low (lumabnaw ang dugo dahil tumaas ang
fluid) BUN and crea decreases also
 serum & urine osmolality ↓ - Because of excessive water,
those solute or electrolytes will tend to decrease by amount.
The concentration of solutes became lower than normal
because of retention of fluid (lumabnaw) In CKD, both serum
and Na level are decreased owing to excessive retention of
water
 urine Na & specific gravity ↓ - Hypervolemia occurs when
aldosterone is chronically stimulated (ie, cirrhosis, heart failure,
and nephrotic syndrome).Therefore, the urine sodium level
does not increase (because of the aldosterone) in these
conditions.↓ Urine Na in hypovolemia because kidneys attempt
to conserve sodium and water to expand the extracellular
volume thus decreasing the amount of Na in the urine.
 chest x-ray may reveal pulmonary congestion - Due to
retention of water in the lung spaces
MEDICAL MANAGEMENT
- Management of FVE is directed at the causes, and if related to
excessive administration of sodium-containing fluids, discontinuing
the infusion may be all that is needed.
Symptomatic treatment consists of administering diuretics and
restricting fluids and sodium.
Pharmacologic Therapy
 Diuretics
 Inhibits the reabsorption of Na and H2o - when dietary
restriction of sodium alone is insufficient. Diuretics are
prescribed to reduce edema by inhibiting the reabsorption
of sodium and water by the kidneys. For example, 80% of
Na should be reabsorbed, much lesser amount will be
reabsorbed
 Severity of the hypervolemic state - The choice of
diuretic is based on the severity of the hypervolemic state.
Whether how much fluid was retained in the body.
Presence of edema, Ascites, Pulmonary edema, pleural
effusion if there are any. How much weight was gained.
Degree of s/sx
 severity of the hypervolemic state degree of
impairment of renal function - Where is the impairment
of function? (what structures has been affected) Kidneys?
PCT? DCT? Loop of Henle? (draw nephron, glomerulus,
bowman’s capsule, PCT, Loop of Henle, DCT, collecting
ducts)
 potency of the diuretic - What does the diuretic inhibits?
Production of what hormones? ADH? Aldosterone? Does it
reabsorbed Na? inhibit H20 production? K excretion? Does
it inhibit Mg, Ca and other electrolytes present?
 Thiazide diuretics
 block Na reabsorption in the DCT - (draw nephron,
glomerulus, bowman’s capsule, PCT, Loop of Henle, DCT,
collecting ducts) Thiazide diuretics block sodium
reabsorption in the distal tubule, where only 5% to 10% of
filtered sodium is reabsorbed (in the DCT). ↑ excretion of
Na, Cl, K, and H20 ↓ Ca secretion, ↑ Mg secretion
 block Na reabsorption in the DCT mild to moderate
hypervolemia - Prescribed to mild to moderate
hypervolemia
 Hydrochlorothiazide - thiazide diuretics, such as
hydrochlorothiazide (microzide) or metolazone (Mykrox,
Zaroxolyn)
 Loop diuretics
 block Na reabsorption in the ascending limb of the
Loop of Henle - Loop diuretics, can cause a greater loss
of both sodium and water because they block sodium
reabsorption in the ascending limb of the loop of Henle,
where 20% to 30% of filtered sodium is normally
reabsorbed. ↑ Na, Cl, K, H20, Ca, Mg, excretion ↑ urine
flow
 severe hypervolemia - Prescribed to severe hypervolemia
 furosemide (Lasix) -
 Furosemide (Lasix)
 Torsemide (Demadex)
 K, Mg, Ca, NaHCO3
- Electrolyte imbalances may result from the effect of the diuretic.
Aside from Na and Cl that may be affected by diuretics there are
other electrolytes present that can be affected such as
K, Mg, Ca, NaHCO3, PO4, H
 Hypokalemia
- Hypokalemia can occur with all diuretics except those that work in
the last distal tubule of the nephrons.
- K can be excreted via urine with diuretics resulting in
hypokalemia except on the DCT that some of it can be reabsorbed
- Draw nephron structure
- Potassium supplements can be prescribed to avoid this
complication.
 Hyperkalemia
 Potassium - sparing diuretics
 Spironolactone
 Hyperkalemia can occur with diuretics that work in the last
distal tubule (eg, spironolactone [Aldactone], a potassium-
sparing diuretic), especially in patients with decreased
renal function.
 ↑ K can occur with POTASSIUM-SPARING DIURETICS
(leaves K for reabsorption) which acts in the DCT
especially if your client has ↓ renal function.
 Draw nephron structure
 Hyponatremia
- Hyponatremia occurs with diuresis due to increased release of
ADH secondary to reduction in circulating volume.
- Decreased in Na will occur via urine DUE TO STIMULATION OF
THE ADH (which tells the kidneys to conserve water and some Na
only) Remember that, ADH release is stimulated by a ↓ circulating
volume
 Hypomagnesemia
- Decreased magnesium levels occur with administration of loop
and thiazide diuretics due to decreased reabsorption and
increased excretion of magnesium by the kidney.
- With loop and thiazide diuretics Mg levels decreases because of
the diuretics action, ↓ reabsorption and ↑ excretion
 Azotemia
- Azotemia (increased nitrogen levels in the blood) can occur with
FVE when urea and creatinine are not excreted owing to
decreased perfusion by the kidneys and decreased excretion of
wastes.
 Hyperuricemia
- High uric acid levels (hyperuricemia) can also occur from ↑
reabsorption and ↓ excretion of uric acid by the kidneys.
DIALYSIS
- If renal function is so severely impaired that pharmacologic
agents cannot act efficiently,
other modalities are considered to remove sodium and fluid from
the body.
 Hemodialysis
- Hemodialysis is a treatment to filter wastes and water from your
blood, AS YOUR KIDNEYS DID WHEN THEY WERE HEALTHY.
Using a machine. Hemodialysis helps control blood pressure and
balance important minerals, such as potassium, sodium, and
calcium, in your blood.
 Peritoneal Dialysis
- Peritoneal dialysis uses a fluid (dialysate) that is placed into the
patient's abdominal cavity (peritoneum) to remove waste products
and fluid from the body.
- Dialysate absorbs waste and fluid from your blood, using your
peritoneum as a filter.
- Dialysate, also called dialysis fluid, dialysis solution or bath, is a
solution of pure water, electrolytes and salts, such as bicarbonate
and sodium.
- The purpose of dialysate is to pull toxins from the blood into the
dialysate.
- The way this works is through a process called diffusion.
 Continuous renal replacement therapy
- slow form of hemodialysis, the patient's blood is removed and
pumped through a hemofilter, which resembles a dialyzer.
- CRRT helps prevent the hemodynamic fluctuations common with
the more rapid IHD
- Review hemodialysis, peritoneal dialysis, CRRT
- Time constraints, another discussion for dialysis
NUTRITIONAL THERAPY
 Dietary restriction of Na
- Treatment of FVE usually involves dietary restriction of sodium.
 6 to 15g of salt/day - An average daily diet not restricted
in sodium contains 6 to 15 g of salt, Adults should eat no
more than 6g of salt a day (2.4g sodium) – that's around 1
teaspoon. Salt also contains the electrolytes magnesium,
calcium and potassium; so it's good for more than just
sodium replenishment.
 250mg of Na/day - whereas low-sodium diets can range
from a mild restriction to as little as 250 mg of sodium per
day, depending on the patient’s needs.
 Mild sodium - restricted diet - A mild sodium-restricted
diet allows only light salting of food (about half the usual
amount) in cooking and at the table, and no addition of salt
to commercially prepared foods that are already seasoned.
 Avoid foods high in Na
 Bacon, sausage, sardines, caviar
 Pizza, burritos
 Spam
 Salted nuts
 Beans
- Smoked, cured, salted or canned meat, fish or poultry
including bacon, cold cuts, ham, frankfurters, sausage,
sardines, caviar and anchovies. Frozen breaded meats
and dinners, such as burritos and pizza. Canned entrees,
such as ravioli, spam and chili. Salted nuts. Beans canned
with salt added.
 Sodium salt contributes to edema
- It is the sodium salt (sodium chloride) rather than sodium itself
that contributes to edema.The salt itself because kidneys can keep
more water in the system. Therefore, patients are instructed to
read food labels carefully to determine salt content.
 Salt substitutes
- Because about half of ingested sodium is in the form of
seasoning, seasoning substitutes can play a major role in ↓ sodium
intake.
PANSALT But only selected outlets available in Philippines
(mercury, Rustan’s, LAZADA)
- Contains Mg and KCl (tastes like NaCl salt)
 Contains K - Most salt substitutes contain potassium and
must therefore be used cautiously by patients taking
potassium- sparing diuretics (eg, spironolactone,
triamterene, amiloride). Some contains Mg, some iodine
  Advanced renal disease - They should not be used at all NUTRITIONAL THERAPY
in conditions associated with potassium retention  Drinking water
(HYPERKALEMIA), such as advanced renal disease. - In some communities, the drinking water may contain too much
 Ammonium chloride - Some salt substitutes contains sodium for a sodium-restricted diet.
ammonium chloride that can be harmful to patients with  1mg of Na - Depending on its source, water may contain
liver damage. So read carefully the contents and properties as little as 1 mg or more than 1500 mg of sodium per
of the salt substitute quart. Imagine a 400 mg of Na is 1 pinch of salt, and
 Lemon juice, onions, and garlic - Lemon juice, onions, everyday you drink water (almost 12 glasses of water)
and garlic are excellent substitute flavorings, although  Distilled water - Patients may need to use distilled water if
some patients prefer salt substitutes. the local water supply is very high in sodium. Water testing
Other substitues: to identify electrolytes and minerals
 Rosemary. Taste: An aromatic herb with a pine-like  Bottled water
fragrance. ...  0 to 1200ml - Bottled water can have a sodium content
 Nutmeg. Taste: Sweet and pungent flavour. ... that ranges from 0 to 1200 mg/L; Per liter of water
 Basil. Taste: Sweet and peppery. ... Almost ¾ of a teaspoon of salt per liter therefore, if
 Cardamon. Taste: A warm, aromatic spice. ... sodium is restricted, the label must be carefully
 Chilli/Cayenne. ... examined for sodium content before purchasing and
 Cinnamon. ... drinking bottled water.
 Chives.  Water softener - Also, patients on sodium-restricted diets
should be cautioned to avoid water softeners that add
Quick sodium and salt converter table sodium to water in exchange for other ions, such as
Salt in grams Sodium in mg This is roughly equivalent to calcium. Presence of Mg and Ca makes water hard (some
1 400 Good pinch of salt have irons too). To soften it or remove those ions, Na is
1.25 500 One-quarter of a teaspoon salt
2.3 920 One-third of a teaspoon salt added. Water softeners contains a high amount of sodium.
2.5 1000 Half a teaspoon salt
4 1600 ¾ of a teaspoon salt  Protein intake
5 2000 One teaspoon salt - Protein intake may be ↑ in patients who are malnourished or
6 2400 1¼ teaspoons salt who have ↓ serum protein levels in an effort to ↑ capillary oncotic
10 4000 2 teaspoons salt pressure and pull fluid out of the tissues into vessels for
12 4800 2½ teaspoons salt excretion by the kidneys.
- Protein may help to pull fluid out of the tissues for excretion by
the kidneys via urine

NURSING MANAGEMENT
- It is important to detect FVE before the condition becomes
severe.
Through proper assessment and once identified and proper
intervention, controlling hypervolemia is our objective
 Rest
 Bed rest favors diuresis of fluid
- Regular rest periods may be beneficial, because bed rest favors
diuresis of fluid.
- Diuresis of fluid, excretion, ↑ urination
 ↑ in EFFECTIVE circulating blood volume and renal
perfusion
- The mechanism of rest is there would be a subsequent increase
in effective circulating blood volume and renal perfusion
- Effective circulating blood, only the normal amount of blood will
circulate and will eventually cause effective renal perfusion causing
kidneys to excrete unnecessary fluids and electrolytes and
reabsorbed necessary electrolytes and amount of fluids.
 Diminished venous pooling - Causing a diminished
venous pooling where blood doesn't flow back properly
to the heart, causing blood to pool in the veins in your
legs
 Vital Signs
 Note for BP, bounding pulse, tachycardia
- Increase fluid volume increase BP, Bounding pulse
- rate maybe normal but bounding is abnormal
- often a sign of excessive fluid in the circulation
- Bounding because the heart tries to pump fluid to the tissues to
an abnormal effort because of the presence of excess fluid
 Intake & Output
 Done daily or at regular intervals to identify excessive
fluid retention
- To assess for FVE, the nurse measures I&O at regular intervals
(if necessary) to identify excessive fluid retention.
- It is good that you keep a weight chart or if the institution has
none, document it together with your nurses notes or keep a
separate sheet if you are to monitor I&O accurately because of the
need.
 Weight
 Measured daily
 2.2 lb = 1L of fluid - The patient is weighed daily, and (if)
rapid weight gain is noted. An acute weight gain of 2.2 lb (1
kg) is equivalent to a gain of approximately 1 L of fluid.
Because conditions predisposing to FVE are likely to be
chronic (malala kapag napabayaan), patients are taught to
monitor their response to therapy by documenting fluid I&O
and body weight changes.
 Breath Sounds
 Assessed at regular intervals
- Breath sounds are assessed at regular intervals in at-risk patients
(older adults), particularly if parenteral fluids are being given.
 Crackles - discontinuous short bubbling sounds
corresponding to the splashing of the fluid in the alveoli
during breathing
 Wheezing - Airflow obstruction may be manifested by
wheezing. The mechanism of wheezing in pulmonary
edema is thought to be narrowing of the small airways
because of bronchial wall edema and intraluminal fluid.
 Diminished breath sounds - due to presence of fluid in
an area of the lungs
 Edema
 Monitor the degree of edema
 Feet and ankles, sacral region - The nurse monitors the
degree of edema in the most dependent parts of the body,
 such as the feet and ankles in ambulatory patients and the
sacral region in patients confined to bed. Dependent
edema is describe as gravity-related swelling in the lower
body. Gravity has the effect of pulling fluid down toward the
earth, causing it too pool in the lowest parts of your body,
such as your feet, legs, or hands
  Pitting edema - Pitting edema is assessed by pressing a
finger into the affected part (normally legs and feet),
creating a pit or indentation that is evaluated on a scale of
1 (minimal) to 4 (severe)
 Peripheral edema
 Measuring the circumference of the extremity -
Peripheral edema is monitored by measuring the
circumference of the extremity with a tape marked in
millimeters (Weber & Kelley, 2014).
 Support arms and legs to ↓ dependent edema - As
appropriate. Dependent edema occurs at legs, feet and
arms due to gravity. The effect of pulling down towards the
earth, causing water to pool down on legs feet and arms
 Other Nursing Management
 Check for LOC
 Maintain safety - Altered LOC. May result from mild
anxiety to confusion and coma
 Positioning - If dyspnea or orthopnea is present, the
patient is placed in a semi-Fowler’s position to promote
lung expansion. Fowler’s position. Sitting to assist with
breathing
 Na and fluid restriction
 Avoid OTC Medications - Sodium and fluid restriction
should be instituted as indicated. Patients are
instructed to avoid over-the-counter (OTC) medications
without first checking with a health care provider,
because they may contain sodium (eg. Alka Seltzer).
 Consider water softeners - If fluid retention persists
despite adherence to a prescribed diet, hidden sources
of sodium, such as the water supply or use of water
softeners, should be considered. Remember, water
follows Na so fluid will be excreted, But use with
caution as it may cause hypernatremia because it has
a high amount of Na
 Parenteral fluids - The rate of parenteral fluids and
the patient’s response to these fluids are also closely
monitored (Frandsen & Pennington, 2014). May
worsen condition. Additional fluid in the body if not
closely monitored. Older adults may suffer from
cardiac overload because of their ↑ cardiac function
 Prevent skin breakdown
 Slow healing process - Implement measures to
prevent skin breakdown due to excess fluid pooling in
the extremities can cause ↓ blood flow to that area
causing slow healing process.
 turn and reposition at regular intervals - If the client
is bedridden, the patient is turned and repositioned at
regular intervals because edematous tissue is more
prone to skin breakdown than normal tissue.
 Pulmonary edema - Watch out for critical complications
such as Pulmonary edema, Fluid accumulation in the lungs
which collects in the air sacs, thus patient having DOB
Leads to impaired gas exchange and may cause
respiratory failure
 Diuretics as ordered - Because most patients with FVE
require diuretics, the patient’s response to these agents is
monitored.Thiazide or loop or potassium-sparing increased
urination and sodium loss. affect blood potassium levels.
thiazide diuretic, your potassium level can drop too low
(hypokalemia), which can cause life-threatening problems
with your heartbeat. Diuretics lower BP
EDUCATING PATIENTS ABOUT EDEMA
 Recognize and understand edema
- Because edema is a common manifestation of FVE, patients
need to recognize its symptoms and understand its importance.
The nurse (should) gives special attention to edema when teaching
the patient with FVE.
 Expansion of the interstitial fluid compartment
- Patient should understand that Edema is an expansion of the
interstitial fluid compartment (third – space), as a result of
(Hall, 2015)
 ↑ capillary fluid pressure
 Depedent edema, heart failure, hypoproteinemia - ↑
capillary hydrostatic pressure (pressure exerted by
blood against the wall of a capillary) (drawing from
notes) Fluid comes out of the capillary going into the
interstitial tissues or spaces (causing edema), such as
in conditions venous pressures become elevated by
gravitational forces (gravity, dependent peripheral
edema) volume expanded states (in heart failure or
with venous obstruction) Decreased plasma oncotic
pressure (as occurs with hypoproteinemia) Decreased
protein in the capillary.
 ↑ capillary fluid pressure, ↓ capillary oncotic pressure -
Oncotic (osmotic) pressure is generated mainly by the
difference of protein concentration between the blood and
interstitial tissue (draw in the notes) The blood has a much
higher content of protein (due to albumin) Thus a ↓
capillary oncotic pressure (means hypoproteinemia) will
cause an (go back to previous slide, ↑ capillary hydrostatic
pressure – fluid will come out to the interstitial tissues,
causing edema) and…(next slide)
 ↑ interstitial oncotic pressure - The more permeable the
capillary barrier is to proteins, the higher the interstitial
oncotic pressure. This pressure is also determined by the
amount of fluid filtration into the interstitium. For example,
increased capillary filtration decreases interstitial protein
concentration and reduces the oncotic pressure. With ↑
interstitial oncotic pressure, there is an ↑ capillary filtration
that decreases interstitial protein concentration and
reduces the oncotic pressure causing water to seep out
into the interstitial tissues
 Localized edema
 Ankle, rheumatoid arthritis - Edema can be localized
(eg, in the ankle, as in rheumatoid arthritis)
 Generalized edema
 Cardiac failure - generalized (as in cardiac failure and
kidney injury) (Sterns, 2014).
 Anasarca - Severe generalized edema is called anasarca.
 Change in the capillary membrane
- Edema occurs when there is a change in the capillary membrane,
increasing the formation of interstitial fluid or decreasing the
removal of interstitial fluid. Increased permeability such as in
burns.
 Na retention
- Sodium retention is a frequent cause of the increased ECF
volume.
 Lymphatics obstruction, ↓ plasma albumin, ↓ in plasma
oncotic pressure
- Obstruction to lymphatic outflow, a plasma albumin level less
than 1.5 to 2 g/dL, or a decrease in plasma oncotic pressure
contributes to increased interstitial fluid volume.
 Heart failure
- The kidneys retain sodium and water when there is decreased
ECF volume as a result of decreased cardiac output from heart
failure.
 Medications that could cause edema
 NSAIDs
 Inhibits natriuretic effect - A thorough medication
history is necessary to identify any medications that
could cause edema, such as nonsteroidal anti-
inflammatory drugs (NSAIDs), NSAID inhibits
synthesis of PGE2 (prostaglandin E2) a principal
mediator of inflammation in diseases such as
rheumatoid arthritis and osteoarthritis inhibits
natriuretic effect excretion of Na in urine, can lead to
increased sodium reabsorption, causing peripheral
edema, which is the most common renal effect of
NSAIDs. Edema and sodium retention are usually mild,
 resulting in weight gain of 1 to 2 kg, and typically occur
within the first week of therapy
 Estrogens
a. Diuretics substances - Several clinical situations
are strongly suggestive that estrogens are diuretic
substances that secondarily promote sodium and
water retention in the body by stimulation of
adreno-cortical hormone secretion. The hormones
progesterone and estrogen play significant roles in
fluid retention. Women tend to retain more water
than usual when estrogen levels are elevated and
progesterone levels decline. This is why bloating is
common in the days leading up to a menstrual
cycle when estrogen production increases.
 Corticosteroids - Has an anti-inflammatory properties
like the NSAIDs. Inhibits prostaglandin E2 synthesis
(the cause of inflammation) which has an effect of fluid
retention. Can increase BP thus increasing blood
volume by fluid retention.
 Antihypertensives
a. Vasodilatory edema - Vasodilatory edema, a
common adverse effect of antihypertensive
therapy with vasodilators, is related to several
mechanisms, including arteriolar dilatation
(causing an increase in intracapillary pressure),
stimulation of the renin-angiotensin-aldosterone
system, and fluid volume retention. vasodilatation
of the arterioles and not venules causing increased
capillary hydrostatic pressures leading to edema
 Ascites
 fluid accumulates in the peritoneal cavity, shortness
of breath, sense of pressure - Ascites is a type of edema
in which fluid accumulates in the peritoneal cavity; it results
from nephrotic syndrome, cirrhosis, and some malignant
tumors. Nephrotic syndrome is a kidney disorder that
causes your body to pass too much protein in your urine.
Nephrotic syndrome is usually caused by damage to the
clusters of small blood vessels in your kidneys that filter
waste and excess water from your blood. The patient
commonly reports shortness of breath and a sense of
pressure because of pressure on the diaphragm.
 preserve or restore the circulating intravascular fluid
volume
- The goal of treatment is to preserve or restore the circulating
intravascular fluid volume. So, it is the focus of our nursing
intervention.
 diuretic therapy, restriction of fluids and Na, elevation of
the extremities, application of anti – embolism stockings
- Prevents further swelling and formation of embolus.
 Paracentesis
- Paracentesis is the removal of fluid in the abdomen (ascites)
 Dialysis, continuous renal replacement therapy
- 3 types of dialysis
1. Hemodialysis
2. Peritoneal dialysis
3. CRRT
The therapy most commonly used is continuous renal replacement
therapy (CRRT). In this slow form of hemodialysis, the patient's
blood is removed and pumped through a hemofilter, which
resembles a dialyzer. CRRT helps prevent the hemodynamic
fluctuations common with the more rapid IHD.