Exam 3 - ECF Volume EXCESS (Hypervolemia)

increased hydrostatic pressure

more fluid pushed into interstitial space (i.e. edema occurs)

too much fluid (fluid overload) typically results from what?

1. elevate - to decrease hydrostatic pressure

2. wrap/compression devices - to push fluid back into vessels by hydrostatic pressure

3. diuretics - to decrease fluid on body

4. medications - to vasodilate vessels

name 4 interventions for fluid overload

1. heart failure
2. kidney failure
3. burns or loss of protein = capillary leaking

name 3 primary causes of fluid overload?

3.5 - 5 g/dL

albumin is a large protein molecule in the blood

NL?

1. malnutrition
2. cirrhosis
3. kidney failure

name 3 possible causes of low albumin

pre-albumin

see changes in 2-3 days

albumin = has half life of 20 days (don't see low albumin levels until already very low)

^^this is why we look at what lab value when evaluating protein in blood?

fluid stays in interstitial space

when there is decreased capillary osmotic pressure - what happens to fluid?

ex. ascites -- fluid stays in abdomen instead of going into blood

(1) elevate and (2) administer albumin - to pull fluid back into vasculature and then urinated out of body

name an example of when fluid stays in the interstitial space?

interventions?

1. Excess isotonic or hypotonic IV fluids
2. Heart failure
3. Renal failure
4. Primary polydipsia (increased thirst)
5. SIADH (Syndrome of inappropriate antidiuretic hormone) secretion - a condition in which the body makes too much ADH, causes the body to retain water
6. Cushing syndrome
7. Long-term use of corticosteroids

from the book

ECF volume excess: causes / etiologies (7)

1. Headache, confusion, lethargy
2. Peripheral edema
3. Jugular venous distention
4. S3 heart sound
5. Bounding pulse, ↑ BP, ↑ CVP
6. Polyuria - production of large amounts of urine (with normal renal function)
7. Dyspnea, crackles, pulmonary edema
8. Muscle spasms
9. Weight gain
10. Seizures, coma

from the book

ECF volume excess: manifestations (10)

**bolded ones are also noted in lecture

1. treat underlying cause
2. remove fluid without producing abnormal changes in electrolytes or osmolality of ECF
3. therapies

from the book

from the book

ECF volume excess: interprofessional care and treatments -- name 3

1. diuretics (lasix) - to promote urine output
2. fluid restrictions
3. possible sodium restrictions
4. paracentesis for ascites
5. thoracentesis for pleural effusion

name the 5 possible therapies for ECF volume excess

increased vascular volume

hypervolemia is defined as what?

1. excessive intake of fluids

2. abnormal retention of fluids (i.e. heart failure, renal failure, o)

3. interstitial-to-plasma fluid shift

name the 3 overarching etiologies of hypervolemia

1. High oral intake of salty foods -- increasing sodium comes with water retention

2. Oliguria, limited urine output (AKI, Renal failure)

3. Aldosterone excess, causing the retention of fluid and salt (cirrhosis, chronic heart failure, primary hyperaldosteronism)

4. High levels of glucocorticoids (steroids, Cushing's disease)

5. Too much sodium containing isotonic fluid

name 5 conditions discussed in class that can cause hypervolemia

BP increases

nursing assessment / monitoring for hypervolemia

be alert for clinical manifestations

what happens to BP?

hematocrit - low, below 40%

osmolality - low, below 275 mOsm/kg

sodium - low, less than 135 mEq/L

urine specific gravity - low (dilute urine > 1.010)

labs with hypervolemia

hematocrit?
osmolality?
sodium?
urine specific gravity?

water intoxication

brain functions

_________ is also known as water poisoning, hyper-hydration, over-hydration, or water toxemia (ingesting too much water)

potentially fatal disturbance in _____________ can result when the normal balance of electrolytes in the body is pushed outside safe limits by excessive water intake

1. increased intracranial pressure
2. altered LOC
3. plasma sodium less than 125 mEq/L
4. decreased hematocrit

name 4 neurologic clinical manifestations of water intoxication

increased intake of water means excess water in plasma and more sodium inside cell

to balance out, water from plasma goes into cell

water floods into cell causing cells to swell leading to increased cranial pressure

how does water intoxication lead to increased intracranial pressure?

1. I&O
2. daily weights
3. vital signs
4. cardio and respiratory status
5. HTT assessment (skin, lungs, edema)
6. neurologic function
7. monitor labs
8. monitor IV sites / therapy
9. restrict fluids or IV therapy

name the 9 aspects of nursing management for fluid imbalances (BOTH excess and deficit)

daily weights -- weight patient at same time every day with same conditions

increase of 1 kg (2.2. lb) = 1000mL (1L) of fluid retention

nursing management from book (BOTH)

what is the most accurate measure of volume status

increase of ___________ = __________ of fluid retention

intake

output

nursing management from book (BOTH)

___________ = oral and IV fluids, tube feedings, retained irrigation solutions

____________ = urine, excess perspiration, wound or tube drainage, vomitus, and diarrhea

decreased BUN, sodium, and hematocrit levels

decreased plasma and urine osmolality (dilute urine)

nursing management from book

lab findings for fluid volume EXCESS

1. pulse = full, bounding, not easily obliterated

2. distended neck veins (jugular venous distention), increased central venous pressure, and high BP

3. be alert for presence of S3

nursing management from book

cardiovascular care - name 3 things to note for fluid volume EXCESS

1. can cause pulmonary congestion and pulmonary edema -- results from increased hydrostatic pressure in pulmonary vessels forces fluid into alveoli

2. SOB and moist crackles upon auscultation

nursing management from book

respiratory care - name 2 things to note for fluid volume EXCESS

edematous

dehydrated, soap

nursing management from book -- good skin care is imperative (BOTH)

elevate __________ extremities -- promotes venous return and fluid reabsorption

____________ skin needs frequent care without use of ___________ -- apply moisturizes or creams which stimulates circulation and increase moisture retention

1. edematous skin may feel cool - from fluid accumulation and decrease in blood flow

2. taut and hard skin from fluid causing stretching

3. edema assessment (rate from +1 to +4)

nursing management from book

skin care - name 3 things to note for fluid volume EXCESS

high intake, normal output

normal intake, deceased output

Mechanisms of Disrupted Fluid and Electrolyte Balance

ECV excess = osmolality too low = plasma electrolyte excesses

2 ways this occurs?

1. excessive intake of fluids, abnormal retention of fluids (HF), or interstitial-to-plasma fluid shift

2. treatment: remove fluid without changing electrolyte composition or osmolality of ECF

3. diuretics and fluid restrictions

4. paracentesis (remove fluid in abdomen) or thoracentesis (remove fluid in lungs)

4 summary points for hypervolemia

1. excess fluid volume
2. risk for imbalanced fluid volume
3. ineffective airway clearance
4. risk for impaired skin integrity
5. disturbed body image
6. risk for injury

potential complication: pulmonary edema, ascites

name 6 nursing diagnoses for hypervolemia

name the 2 potential complications