FLUID VOLUME DEFICIT

FLUID VOLUME EXCESS

THIRD SPACE FLUID SHIFT

FLUID VOLUME DEFICIT

Three Basic Types

Isotonic Dehydration
Hypertonic Dehydration
Hypotonic Dehydration

Isotonic
Dehydration
- Most common
- Loss of isotonic fluids from
the ECF, plasma and
interstitial spaces.
- Loss of F/E at the same
proportion
- Results to inadequate tissue
perfusion

Etiology
Poor intake of fluids and solutes, heavy losses of
isotonic body fluids.
Hemorrhage
Vomiting
Diarrhea
Profuse salivation,
Fistulas, abscesses
Ileostomy, Cecostomy
Frequent enemas Burns,
Prolonged NPO
Diuretic therapy
GIT suction.

HYPERTONIC
DEHYDRATION
Water loss from the ECT>
electrolyte loss osmolarity
of plasma.
Water move from ECT and
interstitial fluid spaces to the
plasma cellular dehydration
and CELL shrinkage.

Etiology

Excessive sweating
Hyperventilation,
Ketoacidosis
Prolonged fevers
Diarrhea,
Early stage renal
failure
DI, RF
Watery diarrhea,
Excessive
Hypertonic
fluid replacement

Excessive NaHCO3 ,
tube feeding
Dysphagia
Impaired thirst
Unconsciousness
Fever
Impaired motor
Function
Systemic infection
Addisons dse

3. HYPOTONIC DEHYDRATION
least common type
results from fluid shifts between spaces, causing decrease
in plasma volume.
loss of Na & K from ECF

blood & interstitial fluid osmolarity

lowers the osmotic pressure

Movement of water from plasma and interstitial

spaces

plasma volume deficit and swelling of cells

neurologic problems.
Etiology
Chronic illness: CRF w/ Na+ wasting, excessive
ingestion/administration of hypotonic fluids,
chronic/severe malnutrition

CLINICAL MANIFESTATIONS FVD

Cellular dehydration

- Thirst
- Dry mucous membranes of mouth and eyes
- Cracked lips and tongue furrows, difficult swallowing
- Tenting of the skin (decreased turgor)
- Soft sunken eyes
- Decrease in systolic BP, weak pulse, HR & PR
- Flat jugular veins in supine position
- Prolonged peripheral venous filling time of more than 5
seconds.
- temperature (vessel constriction)
- Muscle weakness (Na K imbalance)
- Changes in I & O.
- Weight loss
- Hard stool (compensatory reabsorption of fluid from the
colon)
Cerebral signs (intracellular compartmental shifting)
Early signs: apprehension, restlessness, headache
Severe: hallucinations, confusion, coma.

ASSESSMENT
History
Ask about:
Abnormal or excessive fluid losses: sweating, diarrhea,
bleeding, vomiting, urination, salivation, and wound
drainage.
Chronic illness, recent acute illness, recent surgery,
drug regimens.
Urine output, frequency and amount of voiding, usual
fluid intake
Intake during the previous 24 hours
Strenuous physical activity

Diagnostic
Findings
Serum osmolarity

Plasma sodium
BUN
Plasma glucose
Hct
Hgb (hemoconcentration,
hypotonic dehydration w/ plasma
volume deficits)
USG >
CVP

Nursing Dx
Deficient fluid volume r/t excessive fluid loss
(vomiting, diarrhea, hemorrhage, or third-space
fluid loss such as ascites or burns) or
insufficient fluid intake.
Impaired oral mucous membrane R/T lack of
oral intake/ inadequate oral secretions.
Decreased cardiac output r/t decreased plasma
volume.
Risk for injury related to orthostatic
hypotension.
Expected Outcomes:
BP and PR WNL
24-hour fluid intake & fluid output balance.
USG < 1.030
Good skin turgor (-)tenting

MANAGEMENT
Goal: restore normal fluid volume, replace
ongoing losses, correct underlying problem
(vomiting
or diarrhea)
a. Medical
Oral rehydration
OFI, ORS
Avoid chocolate, coffee cola drinks, sugar

1. IV REHYDRATION

Acute or severe losses

Calculated on the clients weight & presence of

any other comorbidities (cardiac, renal, liver or

pulmonary disorders)
Hypotensive clients:
- Isotonic IVF to expand plasma volume (LR, 0.9
NaCL)
Normotensive clients:
- Hypotonic electrolyte solutions (eg, 0.45%
NaCl)
- provide both electrolytes and water for renal
excretion of wastes.
- Na solution are infused at a rate of 0.5 to 1
mEq/L/hr to avoid cerebral edema.

determines whether depressed renal

function is d/t renal blood flow 2 to

FVD (prerenal azotemia) or to acute
Fluid
tubular Challenge
necrosis
100 - 200ml of NSS for 15 min.
Goal: provide fluids rapidly enough
to attain adequate tissue perfusion
w/o compromising the CV system.

2. Drug therapy
Antiemetics
Antidiarrheal drugs
Antibiotics infectious diarrhea
Antipyretic
3. Monitoring for Complications of FVD
Restoration
IVF adm. is based on the clients overall
condition
Severe ECFVD with heart, pulmonary, liver or
kidney disease = at risk of heart failure
Accurate and frequent assessment of I &
O ,WT, V/S, CVP, LOC, Breath sounds

Nursing Management
Restore oral fluid intake

Small amounts of fluid of choice hourly to older,

confused, or debilitated clients

Wet lips and mouth
Give antiemetics
Clear liquids - full liquid - solid foods.
Position properly to avoid aspiration.
Give oral care
Avoid alcohol-based mouthwash.

Restore fluids by intravenous route

Adm. fluids cautiously for clients w/ ECFVD.
Use IV pump to regulate IV infusion
Monitor IV solutions, sites, and client outcomes hourly. (to
prevent overflow diuresis, hypernatrmia, pulmonary
overload)
Reduce the risk of Deficient Fluid Volume
Tube feeding : recommend 1ml dil: 1 kcal of feeding
formula.
(eg. 380 kcal in 240 ml of formula add 140 ml of water
for a total of 380 ml of fluid).
Measure I & O accurately.

Monitor USG
- Monitor skin & tongue turgor
- The skin turgor is not a valid test in elderly
people due to loss of skin elasticity
-

Control the underlying problems

Examine the clients prescription and nonprescription
medication list.
Avoid fatty or fried foods to decrease diarrhea and
enhances digestion
Monitor LOC, V/S, breath sounds, skin color

Be alert for signs of overload

- Mental function is affected due to cerebral
perfusion
- Rapid, weak pulse indicates FVD
- Postural hypotension a drop in systolic BP
exceeding 15 mm Hg from lying to sitting
position
-

FLUID VOLUME
EXCESS

FLUID VOLUME EXCESS/ HYPERVOLEMIA

ECFVE or overhydration.
Excess fluids can be found

- vascular system (hypervolemia)

- interstitial spaces (third-spacing).
Three Types

a. Isotonic overhydration
b. Hypotonic overhydration
c. Hypertonic overhydration
Third Space Fluid Shift

a. Isotonic overhydration:

- expansion of ECF space only

- in water volume & solute concentration (esp Na)
in proportion equal to its normal isoosmolar
state
- No ICF state
b. Hypotonic overhydration
- expansion of both the ECF and ICF compartments
- Water intoxication
- in water volume w/o in Na concentration
- Osmotic fluid shifts from ECF to ICF (Cell swelling)
c. Hypertonic overhydration
- Osmotic fluid shift from ICF to ECF
in Na concentration w/ water volume
remaining normal

THIRD SPACE FLUID SHIFT

shift into potential spaces : pleural, peritoneal,
pericardial, joint cavities, bowel or interstitial
space
Fluids trapped in body space ; unavailable for use
Symptoms & consequences
Ascites peritoneal cavity
Pleural effusion
Pericardial effusion life threatening
Pedal Edema
Anasarca
Pulmonary edema fluid in interstitial spaces in
the
lung; life threatening

ETIOLOGY (FVE)
Compromised regulatory mechanism
a. Kidneys malfunction = inability to excrete
excesses
b. Cardiac failure = accumulation of fluid : lungs
& dependent parts
c. Liver cirrhosis = failure to metabolize 3 basic food
groups (CHO, Fats, CHON)
Excessive administration of Na containing fluids in a pt.
w/ impaired regulatory mechanism
Corticosteroid therapy
Excessive ingestion of table or other Na salts
Hypothyroidism
Lymphatic or venous obstruction
Hyperaldosteronism= Na reabsorption by the kidneys &
GIT
SIADH: dilutional hyponatremia

PATHO FVE MS WORD

GENERAL CLINICAL MANIFESTATIONS

A.Respiratory (Pul. edema/Pleural Effusion)
RR, shallow respirations, dyspnea,
Coughing, dyspnea & crackles
Pallor, cyanosis, decreased tissue perfusion =
impaired O2 and CO2 exchange
Pleural effusion = fluids shifting in pleural spaces d/t
hydrostatic pressure.
B.CV
Systemic venous engorgement d/t delayed emptying
and filling of RV
Jugular vein distention/neck vein engorgement
peripheral vein filling (CRT) >5 sec
Bounding or irregular pulse,PR, CVP, BP PULSE
pressure

C. Accumulation of fluid in interstitial spaces

Edema: feet & sacrum

Anorexia & bloating (stomach) = d/t shifting of

fluid

in visceral

tissues
Rapid wt gain (2 lbs/day or 1L/day of fluid).
Anasarca
D. Integumentary

Pitting edema in dependent areas

Nonpitting edema in areas of loose skin folds stasis,

dermatitis, ulcers
Weeping edema
Skin pale and cool to touch
E. Cerebral dysfunction d/t intracellular fluid shifting

Confusion headache lethargy seizures coma

DIAGNOSTIC FINDINGS
Plasma < 275mOsm/kg
S. Na< 135mEq/L
BUN < 8mg/dl
Hct < 45%
Azotemia - nitrogen levels in the blood
- urea & creatinine not excreted
USG <1.010
CXR= pulmonary congestion
Mg = d/t adm thiazide diuretics

NURSING DIAGNOSIS
Excess fluid volume r/t : heart, renal,

liver failure
Decreased cardiac output r/t heart
failure
Risk for altered skin integrity, injury
Altered comfort
Impaired gas exchange

MANAGEMENT (FVE)
Medical
Restrict Na & fluid intake
Promote urine output

a. Thiazide diuretics : e.g. Hydrochorothiazide

b. Loop diuretics: Furosemide
c. Potassium sparing diuretics: Spironolactone
ACE inhibitors and beta blockers = improves cardiac
function
Hemodialysis or peritoneal dialysis
Diet therapy: CHON diet

NURSING INTERVENTION
Monitor I & O strictly.

Collaborate w/ the dietician in planning Na &

fluid restrictions
Give cold fluids :thirst
Regulate IV accurately.
Use isotonic saline for bladder or NGT irrigations
Suggest alternatives for seasoning: lemon,
garlic, pepper
Avoid long periods of standing
Elevate legs when sitting/lying
Bed rest to promote diuresis ( pts w/ HF)

Elevate head at 30-45

venous return
cardiac workload
allows improved diaphragmatic excursion
promotes jugular venous drainage w/c improves

cerebral perfusion

Administer O2 as prescribed to keep O2

saturation greater than 90%

Monitor for plasma electrolytes
Turn the client frequently
Control moisture and shear
Lubricate the skin of the legs

Assignment

Electrolytes
Hyponatremia
Hypernatremia
Hypokalemia
Hyperkalemia