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Med Surg - Fluid Bal
| Term | Definition |
|---|---|
| 3 fluid compartment areas | Intravascular Transcellular Interstitial Intracellular |
| Intravascular | Within BV |
| Transcellular | Fluid in epithelial lined spaces - i.e peritoneal cavity |
| Interstitial | Fluid between cells, almost bathing them |
| Intracellular | Fluid inside cells |
| 2 Main types of fluid imbalances | Hypervolemia Hypovolemia |
| Hypervolemia | Fluid volume overload d/t: + intake, - loss, fluid shifts |
| Hypovolemia | Fluid volume deficit d/t: - intake, abn. retention (+ loss) |
| Effects of Intravascular imbalances | Can + or - BP |
| Effects of interstitial hypervolemia * | Edema d/t: + BV = swelling |
| Effects of transcellular hypervolemia | Third Spacing |
| Third Spacing | Fluid becomes trapped in peritoneal cavity; too much in wrong place To assess: compare clinical presentation (ascites) to I&O values |
| Cardio. S&S of Hypovolemia * | + HR d/t compensation for low BV Low, thready pulse d/t low BV - BP, ortho HTN , flat veins, - peripheral pulse d/t: blood going to more important places. Dysrhythmias |
| Cardio. S&S of Hypervolemia * | + HR, bounding pulse, dysthymia, + BP d/t + BV Distended veins d/t + pressure + BV |
| Resp.. S&S of Hypovolemia * | + RR d/t quick breathing to + perfusion Dyspnea and SOB |
| Resp. S&S of Hypervolemia * | + RR d/t fluid moving into the lungs SOB Crackles on auscultation d/t fluid |
| Neuro. S&S of Hypovolemia * | Confusion, lethargy, coma, - LOC Dizziness, weakness |
| Neuro. S&S of Hypervolemia * | Confusion, lethargy, coma, - LOC Dizziness, weakness |
| Integumentary S&S of Hypovolemia | Thirst, dry mouth, poor skin turgor, tenting |
| Integumentary S&S of Hypervolemia | Cool, pale skin, Edema d/t too much fluid in interstitial |
| Renal S&S of Hypovolemia | - U/O d/t attempt to retain fluid |
| Renal S&S of Hypervolemia | + U/O d/t kidneys compensating OR - U/O d/t kidneys being damaged |
| GI S&S of Hypervolemia | - BS and motility d/t oxygen going to more important places + constipation d/t dry stool and " " weight loss |
| GI S&S of Hypervolemia * | + BS and motility d/t attempt to void fluids + diarrhea d/t attempt to void fluids weight gain? |
| Fluid Volume Deficit management steps | 1. ID and treat cause 2. Replace fluids and electrolytes 3. Prevent and assess inadequate perfusion |
| FVD Improvement signs | Normalizing BP and HR Improved skin turgor |
| Fluid Volume Overload management steps | 1. ID and treat cause 2. Limit sodium/fluid intake 3. Administer Diuretics |
| FVO improvement signs | Positively trending daily weights, BP and decreased crackle sounds |
| Furosemide (LASIX) | Therapeutic Class: Diuretic Pharmacy Class: Loop Diuretic Action: Increases renal excretion , mobilizes excess fluid and decreases BP Side Effects: Dizziness, headache, HypoTN, electrolyte imbalance. Nrsg Consid: Old ppl - fall risk |
| FVD Complications | Hypovolemic Shock |
| FVO Complications | Pulmonary edema d/t fluid seeping into lungs and decreasing O2 sat., heart failure, impaired gas exchange, HTN |
| Hypovolemic Shock | Life threatening condition where the body doesn't get enough blood flow. Cause: Decreased intravascular fluid volume d/t external fluid loss (bleeding, vom.) or internal fluid loss (fluid shifts b/w intravascular and interstitial spaces - Third spacing) |
| General Shock symptoms | |
| Why does +HR with shock | + HR bc it can + CO which can + Mean arterial pressure which can + overall perfusion and deliver more oxygen to tissues |
| Hypovolemic shock nursing management | 1. Call for help notify MPR 2. Put pt in modified trendelenburg (boost position) 3. Admin IV fluids, meds, and blood products 4. Apply oxygen |
| Potassium (K+) Normal Ranges, clinical significance and uses | 3.5-5.0 mmol/L Essential for cardiac electrical conduction, if too high or low, rhythm change in heart can be fatal Maintains heart and muscle contraction (K+ardiac) |
| Hypokalemia Cause and def | <3.5 Cause: K+ loss, inadequate intake, movement from ECF to ICF |
| Hypokalemia S&S | S&S: Decreased GI motility, Decreased BS, muscle cramps, decrease Deep tendon reflex, confusion, depression, lethargy. Cardiac S&S: Dysrhythmia, irreg. pulse, postural HypoTN, CA. |
| Hypokalemia Interventions | Supplement K+ **If IV admin, must be monitored as HIGH ALERT!** NEVER IV PUSH K+ d/t cardiac effects Watch for falls bc of assoc. muscle weakness. |
| Hyperkalemia cause and def | >5.0 Cause: Excessive K+ intake or decreased secretions |
| Hyperkalemia S&S | Increased GI motility, abn. cramping, increased bowel sounds, muscle twitching leading to muscle weakness, placid paralysis, irritability Cardiac: Bradycardia, hypoTN, irreg. pulse, CA |
| Hyperkalemia Interventions | Admin meds that will lower K+ and support cardiac health (diuretics, insulin, kayexalate, calcium gluconate), falls prevention, cardiac monitoring |
| Sodium (Na+) normal range, clinical significance and use | 135 -145 mmol/L Sodium moves from high to low conc area High = concentrated = fluid volume loss low = diluted = FVO Maintains osmolality as sodium levels determine where water is retained, moved, or excreted. **where sodium goes, water flows** |
| Actual Hyponatremia cause | Na+ excretion of decrease in Na+ intake which results in Decrease serum osmolality |
| Relative Hyponatremia cause | Na+ seems low/ diluted in comparison to high water content which results in Decrease serum osmolality |
| Hyponatremia S&S | **IMPACTS CNS!** - Behaviour changes, increased ICP, confusion, seizures - Muscle weakness - Increased GI motility, N/V/D, cramping - CV symptoms dependant on fluid status (hypervolemia vs hypovolemia) |
| Hyponatremia Interventions | Admin Na+ containing fluids - With normal or excess fluids, admin meds that will remove water and not Na+ (diuretics) |
| Actual Hypernatremia Cause | Increase in Na+ intake or decrease in excretion resulting in increased serum osmolality |
| Relative Hypernatremia cause | fluid loss without Na+ loss or decreased fluid intake resulting in increased serum osmolality |
| Hypernatremia S&S | IMPACTS CNS - behaviour changes, seizure, muscle twitching, cramping, weakness - thirst, dry mucous membranes - CV symptoms dependent on fluid status |
| Hypernatremia interventions | Provide health teaching on Na+ restricted diet admin IV infusion: if related to volume loss (hypotonic or isotonic) admin medications (diuretics) that promote na+ loss CORRECT SLOWLY! - why? |
| Chloride (Cl-) range and use | 95-105 mEq/L Involved in BP and BV maintenance and pH balance |
| Magnesium (Mg2+) ranges and uses | 1.6-2.6 mg/dL Involved in neuromuscular contractility |
| Calcium (Ca2+) range and use | 4.5-5.5 Involved in neuromuscular contractility, coagulation and bone health |
| Phosphate (P) range and use | 1.9-2.6 mEq/L Bone and teeth health, muscle and RBC function, acid base balance |
| PIV (Periph. IV) | Accessin upper extremity short term therapy <7 days monitor for repeated failed/loss of access |
| CVAD (central) | Use when suitable PIV access is unavailable long term therapy suitable for vesicant/irritant medications/nutrition ex: some antibiotics and chemo |
| PICC | enters on upper arm; Cath runs to superior Vena Cava VERY common in clinical settings medium term use RNs w special knowledge can remove and insert |
| Non-Tunneled CVAD | Enters body directly at vessel site (ex: internal or external jug) catheter runs to superior vena cava catheter outside of body at insertion site common in critical pt (shorter term use) CONTRAINDIC: fragile, high infection risk, high dislodging risk |
| Tunned CVAD | Tunneled (Hickman or Broviac) Proximal end tunnelled subcut. from insertion site and Brought out through the skin at an exit site Antimicrobial cuff long term use |
| Implanted CVAD | Implanted (porta-a-cath) Plaaced in chest, abdomen, or inner forearm accessed by special needle (special skill) long term use - common in peds oncology |
| CVAD risk for infections | HIGH! because they connect outside world to the heart = HIGH RISK OF SEPSIS. increases for specific pt pop. such as cancer, co-morbidities = immunocomp., MUST WEAR APPROP. PPE and disinfecting CVAD prior to access and clean access. |
Created by:
gchiarli
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