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. 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 Imbalce 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 Isotonic loss of F&E from ECF F&E are lost in equal proportion Does not affect cell size Depletion of ECF Volume 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. Pre Renal Results from conditions that interrupt the renal blood supply thereby reducing renal perfusion o ECF Volume Depletion Excessive diuresis Hemorrhage GI losses Loss of intravascular fluid into the extravascular space or Third Space Syndrome (due to ascites, peritonitis, pancreatitis, or burns) Loss of skin and mucus membranes o Impaired Cardiac Efficiency Myocardial Infarction Heart Failure Dysrrhytmias Cardiogenic shock Cardiomyopathy Cardiac Tamponade o Low Systemic Vascular Resistance 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 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) 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 Blood transfusion Vasopressor 02 therapy 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 fluid Fluid Volume Excess Isotonic gain of F&E

F&E are gained in equal proportions Osmolarity remains constant Expansion of ECF

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

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) Shrinkage of cells 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 Swelling of cells 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