Friday, November 26, 2010

Deficient Fluid Volume

Deficient Fluid Volume

NANDA Definition
 Fluid volume deficit is the decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

Discussion of the Problem
Fluid volume deficit (FVD), or hypovolemia, occurs when loss of ECF volume exceeds the intake of fluid. In addition, it occurs when water and electrolytes are lost in the same proportion as they exist in normal body fluids, so the ratio or serum electrolytes to water remain the same. It may occur alone or in combination with other imbalances. Early detection and management are vital to prevent potentially life-threatening hypovolemic shock. Risk factors for FVD are as follows: vomiting, diarrhea, GI suctioning, sweating, decreased intake, nausea, inability to gain access to fluids, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, third-space fluid shifts, burns, ascites, and liver dysfunction. Medical conditions that could contribute to fluid volume deficit are as follows: gastrectomy, fecal diversions, eating disorders (anorexia nervosa and bulimia nervosa), diabetes insipidus, DKA, hepatitis, pancreatitis, leukemia, peritoneal renal diaysis, hemodyalysis, BPH, septicemia, and AIDS. Geriatric patients are more apt to develop fluid imbalances. The goals of management are to treat the underlying disorder and return the extracellular fluid compartment to normal, to restore fluid volume, and to correct any electrolyte imbalances.

Nursing Interventions Classification (NIC)
  • Electrolyte Management
  • Fluid Management
  • Fluid Monitoring
  • Fluid Resuscitation

Nursing Outcomes Classification (NOC)
  • Coagulation Status
  • Fluid Balance
  • Hydration
  • Risk Control

Goal and Objectives
  • Patient will be free of hemorrhage wit clotting times WNL.
  • Patient will experience sufficient fluid volume and electrolyte balance as manifested by palpable peripheral pulses, moist mucous membranes, urine output greater than 30 ml/hr, normotensive blood pressure (BP), heart rate (HR) 100 beats/min, consistency of weight, normal skin turgor, electrolyte levels within normal range, and capillary refill.
  • Patient will start behaviors/lifestyle changes to avoid progression of dehydration.
  • Patient will verbalize awareness of causative factors and behaviors essential to correct fluid deficit.

Subjective and Objective Data
  • Changes in mental status
·         Dark/concentrated urine
  • Decreased urine output
  • Decreased venous filling
·         Dry skin/mucous membranes
·         Hemoconcentration, altered electrolyte balance
·         Hypotension, tachycardia, delayed capillary refill
·         Increased pulse rate, body temperature, decreased BP
  • Increased serum sodium
·         Increased urinary output, dilute urine
·         Output greater than input (diuretic use); concentrated urine/decreased urine output (dehydration)
·         Poor skin turgor
  • Possible weight gain
  • Sudden weight loss
  • Thirst
·         Weak peripheral pulses
  • Weakness; thirst; sudden weight loss

Related Factors
  • Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea)
·         Chronic/excessive laxative/diuretic use
·         Consistent self-induced vomiting
  • Electrolyte and acid-base imbalances
·         Excessive gastric losses: diarrhea, vomiting
  • Failure of regulatory mechanisms
·         Fluid shifts from extracellular, intravascular, and interstitial compartments into intestines and/or peritoneal space (edema or effusions)
·         Inadequate intake of food and liquids
  • Increased metabolic rate (fever, infection)
·         NG/intestinal aspiration
·         Osmotic diuresis (from hyperglycemia)
·         Restricted intake: nausea, confusion

Assessment (Dx)
  • Assess alteration in mentation/sensorium, e.g., confusion, agitation, slowed responses, etc. Changes or alteration in mentation/sensorium is may be caused by abnormally high or low glucose, electrolyte abnormalities, acidosis, decreased cerebral perfusion, or developing hypoxia. Impaired consciousness can predispose patient to aspiration regardless of the cause.

  • Assess fluid status in relation to dietary intake. Most fluid comes into the body through drinking, water in foods, and water formed by oxidation of foods. Establishing if the patient is on a fluid restriction is necessary.

  • Auscultate and document heart sounds; note rate, rhythm or other abnormal findings. Cardiac alterations like dysrhythmias may reflect hypovolemia and/or electrolyte imbalance, commonly hypocalemia/hyopocalcemia. Note: MI, pericarditis, and pericardial effusion with/ without tamponade are common cardiovascular complications.

  • Discuss the importance of monitoring weight daily with same scale, and preferably at the same time of day. Weight is the best assessment data for possible fluid volume imbalance. An increased in 2 lbs a week is consider normal.

  • Explore patient history to determine the possible cause of the fluid disturbance or imbalance. Establishing a database of history will aid to give accurate and individualized care for each patient. This can help to guide interventions.

  • Monitor and document vital signs. This will serve as a baseline data for future comparison.

  • Note presence of nausea, vomiting and fever. These factors affect intake, fluid needs, and route of replacement.

  • Assess blood pressure for orthostatic changes (from patient lying supine to high-Fowler’s position or to standing). Note the following orthostatic hypotension significance:
    1. Greater than 10 mm Hg drop: circulating blood volume is decreased by 20%.
    2. Greater than 20 to 30 mm Hg drop: circulating blood volume is decreased by 40%.

            Orthostatic hypotension, also called postural hypotension, is defined as a “temporary lowering of blood pressure (hypotension) due usually to suddenly standing up (orthostatic).” This sudden change in position causes a temporary decrease in blood flow, thus, a deficiency of oxygen to the brain. This leads to symptoms such as lightheadedness, dizziness, feeling about to black out, and tunnel vision, sometimes, a "black out" episode (a loss of consciousness). The symptoms are usually worse when standing and get better with lying down.
            A test used to confirm orthostatic hypotension is called the Tilt-table testing. It involves positioning the patient on a table with a foot-support. The table is then tilted upward. Blood pressure and pulse is measured while symptoms are recorded subsequently in various positions.
            There is no treatment is required for orthostatic hypotension. If someone with orthostatic hypotension faints, they will regain consciousness by simply sitting or lying down. The person is afterward counseled to exercise care and to make it gradual in changing positions from lying to sitting to standing. This simple method can permit the body to adjust to the new position and allow the nerves to circulation of the legs to adjust gradually in older person.

  • Assess and document temperature. Febrile states reduce body fluids by perspiration and increased respiration. This is known as insensible water loss.

  • Assess color and amount of urine. Report urine output less than 30 ml/hr for 2 consecutive hours. Concentrated urine denotes fluid deficit. A normal urine output is considered normal not less than 30ml/hour.

  • Inspect and take note of skin turgor and mucous membranes for signs of dehydration. Signs of dehydration are also seen through the skin. Skin of elderly patients losses elasticity therefore skin turgor should be assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted along the tongue.  

  • Measure and document I&O including vomitus/ gastric aspirate, elimination and urination. Calculate for 24-hour fluid balance. These are good indicators of fluid replacement needs/ effectiveness of therapy.

  • Monitor and document hemodynamic status including CVP, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) if available in hospital setting. This direct measurement serves as optimal guide for therapy.

  • Monitor closely for signs of circulatory overload (headache, flushed skin, tachycardia, venous distention, elevated central venous pressure [CVP], shortness of breath, increased BP, tachypnea, cough) during treatment. This prevents complications associated with fluid replacement therapy.

  • Monitor, document and report abnormal values of serum electrolytes (especially potassium, magnesium), urine osmolality, ABGs (acid-base balance). Fluid deficit is suggested if there is elevated hemoglobin and elevated blood urea nitrogen (BUN). Urine-specific gravity is also increased.

Therapeutic Interventions (Tx)
  • Encourage patient to drink liberal amounts of fluids. Oral fluid replacement is indicated for mild fluid deficit.

  • Help patient if he/ she is unable to feed self. Encourage caregiver to assist with feedings as necessary.

  • If patient can tolerate oral fluids, provide what oral fluids patient prefers. Provide fluid and straw at bedside within easy reach. Provide fresh water and a straw. Most elderly patients may have reduced sense of thirst and may require continuing reminders to drink.

  • Plan daily activities. Planning conserves patients’ energy.

  • Promote comfortable environment by covering patient with light sheets. Avoid situations where patient can experience overheating to prevent further fluid loss.

  • Provide proper and oral hygiene as necessary. This promotes the patients’ interest in drinking fluids.

  • For more severe hypovolemia:
1.     Administer blood products as prescribed by the physician. These may be necessary for active GI bleeding.
2.     Assist in administering parenteral fluids as ordered by the physician. To correct fluid and electrolyte imbalance.
3.     Assist the physician with insertion of a central venous line and arterial line as indicated. This promotes more effective fluid administration and monitoring.

  • Maintain IV flow on prescribed rate.
1.     Stop or slow the infusion if signs of fluid overload occur, refer to physician accordingly. Most susceptible to fluid overload are elderly patient and requires immediate attention.

  • Administer antidiarrheal or antiemetic medications as prescribed. In addition to IV fluids to prevent hypovolemia due to severe diarrhea or vomiting.

  • Administer blood transfusion and parenteral fluids accordingly. To maintain the bowel at rest, the body requires alternative fluid replacement to prevent and correct losses/ anemia. Note: If there is the presence of regional enteritis, fluids and foods containing sodium is restricted.

  • Assist patient in monitoring weight daily. Weight is a good indicator of overall fluid and nutritional status.

  • Provide adequate rest periods; instruct patient to avoid exertion and maintain oral restrictions if indicated. To reduce intestinal fluid losses, the colon is placed at rest for healing.

  • Provide measures to prevent excessive electrolyte loss (e.g., resting the GI tract, administering antipyretics as ordered by the physician). Preventing electrolyte imbalance is essential especially to elderly patient.

Educative (Edx)
  • Discuss the possible cause and effect of fluid losses or decreased fluid intake. This is to encourage the patient to take part in his/her plan of care.

  • Encourage to drink liberal amounts of liquid as tolerated or based on individual needs. Patient may have restricted oral intake in an attempt to control urinary symptoms, reducing homeostatic reserves and increasing risk of dehydration/hypovolemia.

  • Enumerate interventions to prevent or minimize future episodes of dehydration. Patient needs to appreciate the importance of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits.

  • If needed, refer patient to home health nurse or private nurse in able to assist patient. This is a cost effective strategy if patients’ condition is not severe.

  • Stress the importance of maintaining proper nutrition and hydration. To promote and establish cooperation of the patient.

  • Stress to patient and significant others the importance of maintaining prescribed fluid intake including special diet considerations involved. If future episodes occur, patient can rely on home treatment if necessary.

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