FLUID VOLUME
IMPAIRMENT
NCM 212 Concept Lecture on Fluids and Electrolyte
BY AMIE PEREZ DE JESUS
OBJECTIVES
At the end of the lecture, you will be able to:
• Differentiate fluid volume deficit and fluid
volume excess in terms of the following:
• Etiology
• Pathophysiology
• Manifestation
• Diagnostics
• Medical management
• Nursing management
• Nursing diagnosis
• Understand and demonstrate IV therapy.
FLUID VOLUME IMPAIRMENT
There are primarily two types of fluid imbalances
(a) Fluid volume deficit and (b) Fluid volume excess.
Both type of imbalances can be life-threatening and are
often seen in acute care settings.
Patients with many underlying pathologies develop one of
these fluid imbalances and without careful management,
serious and critical conditions may develop
01
FLUID
VOLUME
DEFICIT
FLUID VOLUME DEFICIT
Fluid volume deficit (FVD) is a decrease in intravascular,
interstitial, and/or intracellular fluid in the body.
Fluid volume deficits may be the result of excessive fluid
losses, insufficient fluid intake, or failure of regulatory
mechanisms and fluid shifts within the body.
FVD is a relatively common problem that may exist alone or
in combination with other electrolyte or acid–base
imbalances. (Lemone)
FLUID VOLUME DEFICIT
ISOOSMOLAR FLUID VOLUME DEFICIT
Occurs when sodium and water are lost in equal amounts.
HYPEROSMOLAR FLUID VOLUME DEFICIT
Occurs when more fluid is lost than sodium, resulting in
higher serum osmolality than normal ( > 295 mOsm/kg)
HYPOOSMOLAR FLUID VOLUME DEFICIT
Occurs when electrolyte loss is greater than fluid (rare).
FLUID VOLUME DEFICIT
ETIOLOGY
excessive loss of GI fluids from vomiting, diarrhea,
GI suctioning, intestinal fistulas, and intestinal
drainage.
diuretics, renal disorders, endocrine disorders,
excessive exercise, hot environment, hemorrhage,
and chronic abuse of laxatives and/or enemas.
inability to access fluids, inability to request or to
swallow fluids, oral trauma, or altered thirst
mechanisms.
Older adults are at particular risk for fluid volume
deficit.
FLUID VOLUME DEFICIT
PATHOPHYSIOLOGY
Fluid volume deficit can develop slowly or rapidly, depending on the type of fluid loss.
Loss of extracellular fluid volume can lead to hypovolemia, decreased circulating blood
volume.
Electrolytes often are lost along with fluid, resulting in an isotonic fluid volume deficit.
FLUID VOLUME DEFICIT
PATHOPHYSIOLOGY
When both water and electrolytes are lost, the serum sodium level remains normal,
although levels of other electrolytes such as potassium may fall.
Fluid is drawn into the vascular compartment from the interstitial spaces as the body
attempts to maintain tissue perfusion.
This eventually depletes fluid in the intracellular compartment as well.
FLUID VOLUME DEFICIT
PATHOPHYSIOLOGY
Hypovolemia stimulates regulatory mechanisms to maintain circulation.
The sympathetic nervous system is stimulated, as is the thirst mechanism.
ADH and aldosterone are released, prompting sodium and water retention by the kidneys.
Severe fluid loss, as in hemorrhage, can lead to shock and cardiovascular collapse.
FLUID VOLUME DEFICIT
MANIFESTATION
● Rapid weight loss is a good indicator of fluid volume deficit.
○ Each liter of body fluid weighs about 1 kg (2.2 lb).
○ The severity of the fluid volume deficit can be estimated by the
percentage of rapid weight loss:
○ A loss of 2% of body weight represents a mild FVD; 5%, moderate FVD;
and 8% or greater, severe FVD (Metheny, 2000).
● Loss of interstitial fluid causes skin turgor to diminish. When pinched, the skin
of a patient with FVD remains elevated.
● Postural or orthostatic hypotension is a sign of hypovolemia. A drop of more
than 15 mmHg in systolic blood pressure when changing from a lying to
standing position often indicates loss of intravascular volume.
FLUID VOLUME DEFICIT
MANIFESTATION
● Venous pressure falls as well, causing flat neck
veins, even when the patient is recumbent.
● Compensatory mechanisms to conserve water and
sodium and maintain circulation account for many of
the manifestations of fluid volume deficit, such as
tachycardia; pale, cool skin (vasoconstriction); and
decreased urine output.
● The specific gravity of urine increases as water is
reabsorbed in the tubules.
FLUID VOLUME DEFICIT
MULTISYSTEM EFFECTS OF FLUID VOLUME DEFICIT
● Mucuos Membranes
● Dry; may be sticky
● Decrease tongue size,
longitudinal furrows increase
Urinary
● Decrease urine output
● Oliguria (severe FVD)
● Increase in urine specific gravity
FLUID VOLUME DEFICIT
MULTISYSTEM EFFECTS OF FLUID VOLUME DEFICIT
Neurologic
● Altered mental status
● Anxiety, restlessness
● Diminished alertness/condition
● Possible coma (severe FVD)
Integumentary
● Diminished skin turgor
● Dry skin
● Pale, cool extremities
FLUID VOLUME DEFICIT
MULTISYSTEM EFFECTS OF FLUID VOLUME DEFICIT
Cardiovascular
● Tachycardia
● Orthostatic hypotension (moderate
FVD)
● Falling systolic/diastolic pressure
(severe FVD)
● Flat neck veins
● Decrease venous filling
● Decrease pulse volume
● Decrease capillary refill
● Increase hematocrit
FLUID VOLUME DEFICIT
MULTISYSTEM EFFECTS OF FLUID VOLUME DEFICIT
Metabolic Processes Potential Complication
● Decrease body temperature
● Hypovolemic shock
(isotonic FVD)
● Increase body temperature
Musculoskeletal
(dehydration) ● Fatigue
● Thirst
● Weight loss
○ 2-5% mild FVD
○ 6-9% moderate FVD
○ >10% severe FVD
FLUID VOLUME DEFICIT
DIAGNOSTICS
Laboratory and diagnostic tests may be ordered when fluid volume deficit is suspected.
Such tests measure the following:
Serum electrolytes. Serum osmolality.
● In an isotonic fluid deficit, ● Measurement of serum
sodium levels are within normal osmolality helps to differentiate
limits; when the loss is water isotonic fluid loss from water
only, sodium levels are high. loss. With water loss, osmolality
Decreases in potassium are is high; it may be within normal
common. limits with an isotonic fluid loss.
FLUID VOLUME DEFICIT
DIAGNOSTICS
Laboratory and diagnostic tests may be ordered when fluid volume deficit is suspected.
Such tests measure the following:
Hemoglobin and hematocrit. Urine specific gravity and
● The hematocrit often is elevated osmolality.
due to loss of intravascular ● As the kidneys conserve water,
volume and hemoconcentration. both the specific gravity and
osmolality of urine increase.
FLUID VOLUME DEFICIT
DIAGNOSTICS
Laboratory and diagnostic tests may be ordered when fluid volume deficit is suspected.
Such tests measure the following:
Central venous pressure (CVP).
● The CVP measures the mean
pressure in the superior vena
cava or right atrium, providing an
accurate assessment of fluid
volume status.
Central venous pressure (CVP)
● is the blood pressure in the venae cavae, near the
right atrium of the heart.
● CVP reflects the amount of blood returning to the
heart and the ability of the heart to pump the blood
back into the arterial system.
● It is acquired by threading a central venous
catheter (subclavian double lumen central line
shown) into any of several large veins. It is
threaded so that the tip of the catheter rests in
the lower third of the superior vena cava.
● The pressure monitoring assembly is attached to
the distal port of a multilumen central vein
catheter.
Central venous pressure (CVP)
The CVP catheter is an important tool used to assess right
ventricular function and systemic fluid status.
● Normal CVP is 2-6 mm Hg.
● CVP is elevated by :
○ overhydration which increases venous return
○ heart failure or PA stenosis which limit venous
outflow and lead to venous congestion
○ positive pressure breathing, straining,
● CVP decreases with:
○ hypovolemic shock from hemorrhage, fluid shift,
dehydration
○ negative pressure breathing which occurs when
the patient demonstrates retractions or
mechanical negative pressure which is
sometimes used for high spinal cord injuries.
FLUID VOLUME DEFICIT Correction of fluid loss depends on the acuteness and
severity of the fluid deficit. Goals are to replace F/E (Na
MEDICAL MANAGEMENT: primarily) that have been loss.
FLUID RESTORATION
ORAL REHYDRATION
● The safest and most effective
● For mild fluid deficits in which a loss of electrolytes has
been minimal (e.g., moderate exercise in warm weather),
water alone may be used for fluid replacement.
● *When the fluid deficit is more severe and when electrolytes
have also been lost, a carbohydrate/electrolyte solution
such as a sports drink, ginger ale, or a rehydrating solution
(e.g., Pedialyte or Rehydralyte) is more appropriate. These
solutions provide sodium, potassium, chloride, and calories
to help meet metabolic needs.
FLUID VOLUME DEFICIT
MEDICAL MANAGEMENT: FLUID RESTORATION
IV REHYDRATION
● When the fluid deficit is severe or the
patient is unable to ingest fluids, the IV
route is used to administer replacement
fluids.
FLUID VOLUME DEFICIT
MEDICAL MANAGEMENT:
MONITOR FOR COMPLICATIONS OF FLUID RESTORATION
● Client with severe ECFVD accompanied by severe heart, liver and
kidney disease can’t tolerate large volumes of fluid or sodium
without the risk of development of heart failure
● Unstable clients needs to be monitored to detect ↑ pressure from
fluids
1) Fluid volume status by CVP insertion
2) Lab values (Na, K, BUN, Osmolarity)
3) Body Weight
4) Urine output
FLUID VOLUME DEFICIT
MEDICAL MANAGEMENT:
CORRECTION OF UNDERLYING PROBLEM
Medication
● Antiemetic
● Antidiarrheal
● Antibiotics
● Antidiuretics
FLUID VOLUME DEFICIT
NURSING MANAGEMENT
Nurses are responsible for
(1) identifying patients at risk for
fluid volume deficit,
(2) initiating and carrying out
interventions to prevent and treat
fluid volume deficit,
(3) monitoring the effects of
therapy.
FLUID VOLUME DEFICIT
NURSING MANAGEMENT
● I & O every 8o or hourly (Record all output accurately)
● VS every 2-4 o, report changes from baseline VS; Assess CVP every
4hrs (if patient has cvp access)
● Weight patient daily and record
● Peripheral vein filling (Capillary refill 3-5 sec)
● Renal client / relatives to report urine output ‹ than 30 m/L x 2
consecutive hours or ‹ 240 ml x 80 period
https://www.youtube.com/
watch?v=sO_bxHeGngc&t
FLUID VOLUME DEFICIT https://www.youtube.co
m/watch?v=H9vj1O17l
=151s NURSING MANAGEMENT YU
● Assess for dryness of mucous membrane and skin turgor (check should be
done)
● Oral care to ↓ discomfort related to mucous membrane dryness
● Monitor plasma sodium, BUN, Glucose, HCT to determine osmolality
● Assess the client for confusion, easy indication of ICF involvement.
● Keep fluids easily accessible
● Administer and monitor intake of oral fluids as prescribed.
● Administer IV fluids as prescribed using an infusion pump. Monitor for indicators
of fluid overload if rapid fluid replacement is ordered: dyspnea, tachypnea,
tachycardia, increased CVP, jugular vein distention, and edema.
INTRAVENOUS THERAPY
https://www.youtube.com/watch?v=JfLncYX190E&t=87
8s&fbclid=IwAR2EztdUGsojNupBPHZFWMyI5rx_AlPE
UKZJeCBweKt1EE6bjRPg6pOnQTQ
FLUID VOLUME DEFICIT
ALTERNATIVE ACCESS ROUTES
CENTRAL VENOUS CATHETERS
● Central venous catheters terminate in the superior
vena cava near the heart.
● They are used when peripheral sites are inadequate
or when large amounts of fluid or irritating
medication must be given.
● Central catheter devices include a percutaneous
catheter, peripherally inserted central catheter
(PICC), tunneled catheter, and implanted port.
FLUID VOLUME DEFICIT
CENTRAL VENOUS CATHETERS
● These devices can have one, two, or three
lumens in the catheter or one or more port
chambers.
● Each lumen exits the site in a separate
line, called a tail. Multilumen catheters
allow for the administration of
incompatible solutions at the same time.
● Be careful not to confuse a central
catheter with a dialysis catheter.
● Dialysis catheters should be used only for
dialysis and not for IV therapy, and should
be accessed only by physicians or
specially trained dialysis nurses.
FLUID VOLUME DEFICIT
CENTRAL VENOUS CATHETERS
PERCUTANEOUS CENTRAL CATHETER
● A percutaneous central catheter is inserted
by a physician into the jugular or subclavian
vein. After insertion, correct placement is
determined by x-ray before the catheter is
used.
● These short-term central venous catheters
may remain in place up to several weeks, but
usual placement time is 7 days. These
catheters are inserted at the bedside and are
cost effective for short-term central venous
access in the acute care setting.
FLUID VOLUME DEFICIT
CENTRAL VENOUS CATHETERS
PERIPHERALLY INSERTED
CENTRAL CATHETER (PICC)
● A PICC line is a long catheter that is
inserted in the arm and terminates in
the central circulation. This device is
used when therapy will last more than
2 weeks or the medication is too
caustic for peripheral administration.
FLUID VOLUME DEFICIT
CENTRAL VENOUS CATHETERS
TUNNELED CATHETERS
● Central venous tunneled catheters
(CVTCs) are intended for use for
months to years to provide long-term
venous access. CVTCs are composed
of polymeric silicone with a Dacron
polyester cuff that anchors the
catheter in place subcutaneously. The
catheter tip is placed in the superior
vena cava.
FLUID VOLUME DEFICIT
CENTRAL VENOUS CATHETERS
● Ports
● A port is a reservoir that is surgically implanted into a
pocket created under the skin, usually in the upper
chest. An attached catheter is tunneled under the skin
into a central vein. An advantage of a port is that, when
not in use, it can be flushed and left unused for long
periods.
● Ports can be used to administer chemotherapeutic
agents and antibiotics that are toxic to tissues and
are suitable for long-term therapy. Ports should be
accessed only by specially trained RNs. Most ports
require the use of special noncoring needles that are
specifically designed for this purpose.
THANKS
Does anyone have any questions?
You can message me thru my FB Account
FB Name: Ei Mie
amiesperez@gmail.com
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