FLUID VOLUME DEFICIT:
When the fluid intake of the body is not sufficient to fulfill the fluid requirements of the body, then dehydration occur.
TYPES OF THE FLUID VOLUME DEFICITS:
ISOTONIC DEHYDRATION: Also known as hypovolemia
- It is the type of the fluid volume deficit in which the water and dissolved electrolytes are lost in equal proportion.
- It results in decreased circulating blood volume and inadequate tissue perfusion.
HYPERTONIC DEHYDRATION:
- It is that type of fluid volume deficit in which water loss exceeds electrolyte loss.
- Fluid moves from the intracellular compartments into the plasma and the interstitial fluid spaces
- It results in cellular dehydration and shrinkage.
HYPOTONIC DEHYDRATION:
- It is opposite to hypertonic dehydration. In it, electrolytes loss exceeds water loss.
- It occurs when fluid shift between compartments, causing a decrease in plasma volume.
- Fluid shift from the plasma and interstitial fluid spaces into the cells
- Causing the cells to swell.
CAUSES OF THE FLUID AND VOLUME DEFICIT
| ISOTONIC DEHYDRATION | HYPERTONIC DEHYDRATION | HYPOTONIC DEHYDRATION |
| Inadequate fluid and solutes intake | excessive perspiration | chronic illness |
| fluid shift between compartments | hyperventilation | excessive fluid replacements |
| excessive loss of the isotonic body fluid | prolonged fevers | kidney disease |
| diarrhea, ESKD, diabetes insipidus | chronic malnutrition |
ASSESSMENT FINDING OF THE FLUID VOLUME DEFICIT
| CARDIOVASCULAR Thready, increased pulse rate decreased blood pressure and orthostatic hypotension flat neck and hand veins in dependent positions diminished peripheral pulses decreases central venous pressure dysrhythmias |
| RESPIRATORY Increased rate and depth of respirations Dyspnea |
| NEUROMUSCULAR Decreased central nervous system activity, from lethargy to coma Fever, depending on the amount of the fluid loss skeletal muscle weakness |
| RENAL Decreased urine output |
| INTEGUMENTARY Dry skin Poor turgor, tenting Dry mouth |
| GASTROINTESTINAL Decreased motility and diminished bowel sounds Constipation Thirst Decreased body weight |
| LABORATORY FINDINGS Increased serum osmolality Increased hematocrit Increased blood urea nitrogen BUN level Increased serum sodium level Increased urinary specific gravity |
INTERVENTIONS
- Prevent further fluid losses
- Increased fluid compartment volumes to normal range
- Provide oral rehydration therapy if possible
- If the dehydration is severe, then provide IV fluid replacement
- Monitor input and output
- In general, isotonic dehydration is treated with isotonic fluid solutions, hypertonic dehydration with hypotonic fluid solutions, and hypotonic dehydration with hypertonic fluid solutions.
- Administer medications, such as antidiarrheal, antimicrobial, antiemetic, and antipyretic medications, as prescribed to correct the cause and treat any symptoms.
- Monitor electrolyte values
- Prepare to administer medication to treat an imbalance, if present.
FLUID VOLUME EXCESS:
Fluid retention or fluid intake exceeds the fluid needs of the body.
Also called OVERHYDRATION or FLUID OVERLOAD
Goal of treatment:
- To restore fluid balance
- correct electrolyte imbalances if present
- eliminate or control the underlying cause of the overload.
TYPES OF THE FLUID VOLUME EXCESS:
ISOTONIC OVERHYDRATION:
- Known as HYPERVOLEMIA
- Results from excessive fluid in the extracellular fluid compartments
- Only the extracellular fluid compartments are expanded
- Fluid does not shift between the extracellular and intracellular compartments
- Causes circulatory overload and interstitial edema
- When severe or when it occurs in a patient with poor cardiac function. the chances of heart failure and pulmonary edema may arise.
HYPERTONIC OVERHYDRATION
- It is rare
- caused by the excessive intake of sodium
- Fluid is drawn from the intracellular fluid compartments
- The extracellular fluid volume expands
- Intracellular fluid volume contracts.
HYPOTONIC OVERHYDRATION
- Also known as WATER INTOXICATION
- Excessive fluid moves into the intracellular space
- All body fluid compartments expand
- As a result of dilution, electrolyte imbalance occurs.
CAUSES OF FLUID OVERLOAD:
| ISOTONIC OVERHYDRATION HYPERVOLEMIA | HYPERTONIC OVERHYDRATION | HYPOTONIC OVERHYDRATION |
| Inadequately controlled IV therapy | Excessive sodium intake | Early kidney disease |
| Kidney disease | Rapid infusion of the hypertonic saline | Heart failure |
| Long term corticosteroid therapy | Excessive sodium bicarbonate therapy | Irrigation of the wounds and body cavities with hypotonic fluids Replacements of the isotonic fluid loss with hypotonic fluid Inadequately controlled IV therapy |
ASSESSMENTS OF FLUID VOLUME OVERLOAD
| CARDIOVASCULAR Bounding, increased pulse rate Elevated blood pressure Distended neck and hand veins Elevated central venous pressure Dysrhythmias |
| RESPIRATORY Increased respiratory rate Dyspnea Moist crackles on auscultation |
| NEUROMUSCULAR Altered level of consciousness Headache Visual disturbance skeletal muscle weakness Paresthesias |
| RENAL Increased urine output if kidney can compensate Decreased urine output if kidney damage occurs |
| INTEGUMENTARY Pitting edema in dependent area Pale, cool skin |
| GASTROINTESTINAL Increased motility in GT tract Diarrhea Increased body weight Liver enlargement Ascites |
| LABORATORY FINDINGS Decreased serum osmolality Decreased hematocrit Decreased BUN level Decreased serum sodium level Decreased urine specific gravity |
INTERVENTIONS
- Prevent further fluid overload
- Restore normal fluid balance
- Administer diuretics
- osmotic diuretics may be given to the patient initially to prevent severe electrolyte imbalances
- Restrict fluid and sodium intake as prescribed
- Monitor intake and output
- Monitor weight
- Monitor electrolyte values
- Prepare the patient to administer medication to treat an imbalance if present.
PRACTICE NCLEX BASED QUESTIONS RELATED TO FLUID VOLUME OVERLOAD AND FLUID VOLUME DEFICIT
- The nurse is caring for a client with the heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? a. Weight loss and dry skin b. Flat neck and hand veins and decreased urinary output c. An increase in blood pressure and increased respirations d. Weakness and decreased central venous pressure CVP
- The nurse is reading a primary health care provider’s PHCP progress notes in the client’s record and reads that the PHCP has documented “insensible fluid loss of approximately 800mL daily.” the nurse makes a notation that insensible fluid loss occurs through which type of excretion? a. Urinary output b. Wound drainage c. Integumentary output d. The gastrointestinal tract
- The nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? a. A client with an ileostomy b. A client with heart failure c. A client on long term corticosteroid therapy d. A client receiving frequent wound irrigations
- The nurse caring for a client who has been receiving intravenous IV diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? a. Weight loss and poor skin turgor b. Lung congestion and increased heart rate c. Decreased hematocrit and increased urine output d. Increased respirations and increased blood pressure
- On review of the clients’ medical records, the nurse determines that which client is at risk fluid volume excess? a. The client taking diuretics who has tenting of the skin. b The client with an ileostomy from a recent abdominal surgery. c. The client who requires intermittent gastrointestinal suctioning. d. The client with kidney disease and a 12-year history of diabetes mellitus.
ANSWERS TO THE PRACTICE QUESTION
1(C). Rationale : A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, wight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. weakness can be present in either fluid volume excess or deficit.
2(C). Rationale: Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.
3(A). Rationale: A Fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long – term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.
4(A). Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.
5(D). Rationale : A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileotomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.
Reference: Saunder’s comprehensive review for the NCLEX-RN exam