Republic of the Philippines UNIVERSITY OF NORTHERN PHILIPPINES Vigan City GRADUATE SCHOOL Masters of Arts in Nursing NG202 Advanced

d Pathophysiology

Richmund Earl A. Geron MAN Student

Julieta T. Guinid, RN, MAN Professor

ALTERATIONS IN FLUID VOLUME Fluid Balance occurs if normally, the intake is equal to output. The desirable amount of fluid intake and loss in adults ranges from 1500 to 3500 mL each 24 hours. The average is 2500 mL. Fluid Imbalance occurs if there is a change in ECF volume or in Sodium balance or both. It is of two basic types: Isotonic and Osmolar Fluid Imbalance Isotonic Fluid Imbalance Water and Na are gained or lost in equal proportions ECF osmolarity remains constant, only volume changes No effect in cell size Depletion/Expansion Fluid Volume. Deficit or Fluid Volume Excess

Fluid Volume Deficit or Hypovolemia Causes For kidneys to function properly, the kidney requires 1) normal blood flow, 2) Functioning glomeruli, tubules (kidney) to separate and process an ultrafiltatre containing waste products from blood , 3.) Drainage and elimination of formed urine from the body. Any interruption of any these processes will lead to Fluid Volume Deficit. Pre Renal Results from conditions that interrupt the renal blood supply thereby reducing renal perfusion thus decrease in GFR. o ECF Volume Depletion Excessive dieresis (use of diuretics, polyuria) Hemorrhage (bleeding) GI losses (GI suction, diarrhea, vomiting) Loss of intravascular fluid into the extravascular space or Third Space Syndrome (due to ascites, peritonitis, pancreatitis, or burns) o Fluid shifts from vascular space into an area where it is not readily accessible as ECF Loss of skin and mucus membranes Isotonic loss of F&E from ECF F&E are lost in equal proportion thus the ratio of electrolytes and fluids remains the same Does not affect cell size due to no fluid shifting from ECF to cells (intracellular) Depletion of ECF Volume

o Impaired Cardiac Efficiency Myocardial Infarction Heart Failure Dysrrhytmias Cardiogenic shock Cardiomyopathy Cardiac Tamponade

conditions leading to decrease cardiac contractility and cardiac output leading to renal hypoperfusion

o Low Systemic Vascular Resistance (resulting to vasodilation) Septic Shock Antihyperstensive Drugs Intra Renal Results from injuries to the kidneys. It depends on what kidney site is damaged. o Prolonged Renal Ischemia Pigment nephropathy Myoglubinuria o Nephrotoxic Agents Aminoglycosides NSAIDs ACE inhibitors Heavy metals o Infectious Process Pyelonephritis Acute Glomerular Nephritis Post Renal Results from obstructions to urine flow below the kidneys leading to increase pressure on kidneys and decrease in GFR o Extra-Ureteral Obstruction Prostate Cancer Bladder Cancer Cervical Cancer o Ureteral Obstruction (Bilateral in Renal Failure) Nephrolithiasis Thrombosis Pyogenic debris or sloughed papillae o Bladder neck obstruction Benign Prostatic Hypertrophy (BPH) Prostate Cancer Bladder Cancer o Urethral Obstruction Urethral valves Urethral stricture Clinical Manifestations Complaints of weakness and thirst Weight loss Cardiovascular changes decrease Central Venous Pressure and blood pressure, weak rapid pulse Inc Respiratory rate, Inc temp Renal- >30mL/hr then may drop, decrase urine volume Integumentary cool, pale skin, poor turgor Altered Level of Consciousness (LOC) due to decreasing cerebral perfusion o Unconsciousness if severe fluid loss Sunken eyeball, decrease tearing

Hypovolemic shock Lab data: INCREASE urine specific gravity, hct, BUN, serum osmolality

Medical management Fluid replacement helps normalize blood pressure and restore blood volume. Oral fluids arent enough to adequately treat hypovolemia. Isotonic fluids are given to expand circulating volume. Blood transfusion if severe hemorrhage Vasopressor dopamine, to support blood pressure until fluid levels are back to normal 02 therapy to ensure sufficient tissue perfusion Fluid Challenge Test administration of IVF at specific rates aand interval while hemodynamic response of patient is monitored.

Nursing Responsibilities Monitor fluid intake and output Checked daily weight (a 1lb(0.45kg) weight loss equals a 500 ml fluid loss) Monitor hemodynamic values such as CVP Monitor results of laboratory studies Assess level of consciousness Administer and monitor I.V. fluids Apply and adjust oxygen therapy as ordered If patient is bleeding, apply direct continuous pressure to the area and elevate it if possible Assess skin turgor Assess oral mucous membranes Turn the patient at least every 2 hours to prevent skin breakdown Encourage oral fluids

Fluid Volume Excess Causes Excessive fluid and Na intake Retention of fluid and Na o Renal Failure, Heart Failure, Cushings Dse, Hyperaldosteronism, Nephrotic Syndrome Shifting of fluid into the vascular space o Hypertonic fluids (especially in treatment for burn) Isotonic gain of F&E F&E are gained in equal proportions Osmolarity remains constant Expansion of ECF

Clinical Manifestations Weight gain, edema Cardiovascular changes full, bounding pulse, Increase in BP and Central Venous Pressure Distended neck and peripheral veins Respiratory changes tachycardia, moist crackles, dyspnea Renal polyuria or oliguria

Mental confusion Diagnostic: Dec urine sp. Gravity, hct, BUN, dec serum osmolality Pulmonary congestion, low oxygen level

Medical Management Fluid and Na restriction Treatment of the underlying cause Diuretics Hemodialysis if kidneys arent working properly, diuretics may not be enough to rid the body of extra fluid.

Nursing Responsibilities Monitor fluid intake and output Monitor daily weight, lab results Fluid and Na restriction as ordered Monitor cardiopulmonary status Auscultate breathe sounds Assess for complaints of dyspnea Monitor chest x-ray results Monitor arterial blood gas values Monitor infusion of I.V. solutions Monitor the effects of prescribed medications

Osmolar Fluid Imbalance Water and Na are gained or lost in unequal proportion Serum osmolarity is altered Changes cell size Hyperosmolar, Hypo-osmolar

Hyperosmolar Fluid Imbalance Dehydration/Hypernatremia Results from water deficit or ECF solute excess Inc. serum osmolality (Hyperosmolar) due to electrolytes especially Na is retained with fluid loss Shrinkage of cells due to increased concentration of Na, it pulls fluid out of the cell

Causes Decrease water intake o Unconscious, coma, elderly, infants Increase fluid output o Diabetes Insipidus, watery diarrhea Increase solute intake o Hypertonic enteral feedings without adeqauet water supply esp in treating burn

Clinical Manifestations Extreme thirst Oliguria Weakness Decrease in salivation Increase Heart Rate, decrease BP

Dry mucous membranes, skin, sunken eyeballs, poor skin turgor Lab data: INCREASE serum osmolality, serum Na, hct, BUN, urine sp. Gravity

Medical Management Treatment of underlying cause Fluid Replacement

Nursing Responsibilities Assess clinical manifestations: v/s, I & O, weight, skin turgor and lab results Promote safety Eliminate cause of imbalance Replace fluids hypotonic, low sodium fluid Skin and mouth care

Hypo-osmolar Fluid Imbalance Water intoxication/hyponatremia Water is gained in excess of electrolyte Hypo-osmolarity / decrease in serum osmolality because of Sodium loss Swelling of cells due to excessive low sodium ECF is hypotonic to cells; the cells are hypertonic to the fluid. Because of this imbalance, fluid shifts by osmosis into the cells which have comparatively less fluid and more solutes causing the cells to swell.

Causes Inc. intake of water Physiologic disturbance o SIADH (Syndrome of Inappropriate Anti Diuretic Hormone) Rapid infusion of hypotonic soln

Clinical Manifestation (-)thirst Weakness Decrease urine output with physiologic disturbance Neurologic changes Increase intracranial pressure, confusion Lab data: DECREASE serum Na, hct, BUN, urine sp. Gravity

Medical Management Fluid restriction for water intoxication Diuretics for water intoxication\ Administration of saline solution for sodium deficiency

Nursing Responsibilities Assess clinical manifestations neuro changes, v/s, I & O Monitor lab results Restrict fluids as indicated Weigh patient daily Provide safe environment