Medical Surgical Nursing I

Fluid and Electrolytes:

Fluid Volume Deficit
Fluid Volume Excess

Submitted to: Prof. Ronnie Tiamson
Submitted by: Michaela Katrina A. Trinidad
BSN III 2


Written Report Outline: Fluid Volume Deficit & Fluid Volume Excess
1. Short background about Fluids and Electrolytes
2. Fluid Volume Deficit
a. Types of FVD
b. Etiology
c. Pathophysiology
d. Clinical Manifestations
e. Diagnostic and Laboratory Procedures
f. Medical Management
3. Fluid Volume Excess
a. Types of FVD
b. Etiology
c. Pathophysiology
d. Clinical Manifestations
e. Diagnostic and Laboratory Procedures
f. Medical Management

FLUID AND ELECTROLYTES Normal Function
Body fluids consist of intracellular and extracellular fluid. The intracellular fluid makes up
about 2/3 of the body water. The extracellular fluid makes up the remainder and consists of:
1. Interstitial fluid - fluid between the cells.
2. Plasma and lymph - the intra-vascular fluid.
3. Cerebrospinal fluid - found in ventricles of brain and surrounding the brain and spinal
cord.
4. G.I. tract fluids - gastric, pancreatic and intestinal juices.
5. Synovial fluid - found inside synovial joint capsules.
6. Eye and ear fluids - aqueous and vitreous humours, perilymph and endolymph.
7. Pleural, pericardial and peritoneal fluids.
8. Glomerular filtrate.
One of the primary functions of the kidney is to regulate extracellular fluid pressure. There are
two components of extracellular fluid pressure:
1. Hydrostatic (blood) pressure - Blood pressure depends on:
a. The volume of the extracellular fluids.
b. The diameter of the peripheral blood vessels.

2. Osmotic pressure - depends on the
a. Levels of non-diffusing proteins in plasma and interstitial fluids.
b. The concentration of electrolytes, especially Na+.




FLUID VOLUME DEFICIT
Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids
into the third space, or from a reduced fluid intake. Common sources for fluid loss are the
gastrointestinal (GI) tract, polyuria, and increased perspiration. Fluid volume deficit may be an
acute or chronic condition managed in the hospital, outpatient center, or home setting. The
therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment
to normal. Treatment consists of restoring fluid volume and correcting any electrolyte
imbalances. Early recognition and treatment is paramount to prevent potentially life-threatening
hypovolemic shock. Elderly patients are more likely to develop fluid imbalances.
Related Factors
Inadequate fluid intake
Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea)
Failure of regulatory mechanisms
Electrolyte and acid-base imbalances
Increased metabolic rate (fever, infection)
Fluid shifts (edema or effusions)
Defining Characteristics
Decreased urine output
Concentrated urine
Output greater than intake
Sudden weight loss
Decreased venous filling
Hemoconcentration
Increased serum sodium
Hypotension
Thirst
Increased pulse rate
Decreased skin turgor
Dry mucous membranes
Weakness
Possible weight gain
Changes in mental status
Medical Management for Fluid Volume Deficit
Traditional clear fluids are not appropriate for ORT. Many contain excessive concentrations of
CHO and low concentrations of sodium. The inappropriate glucose-to-sodium ratio impairs
water absorption, and the large osmotic load creates an osmotic diarrhea, further worsening the
degree of dehydration.
ORT for mild or moderate dehydration
o Mild or moderate dehydration can usually be treated very effectively with ORT.
o Vomiting is generally not a contraindication to ORT. If evidence of bowel obstruction, ileus, or
acute abdomen is noted, then intravenous rehydration is indicated.
o Calculate fluid deficit. Physical findings consistent with mild dehydration suggest a fluid
deficit of 5% of body weight in infants and 3% in children. Moderate dehydration occurs with
a fluid deficit of 5-10% in infants and 3-6% in children (see Table 1 and Table 2). The fluid
deficit should be replaced over 4 hours.
o The oral rehydration solution should be administered in small volumes very frequently to
minimize gastric distention and reflex vomiting. Generally, 5 mL of oral rehydration solution
every minute is well tolerated. Hourly intake and output should be recorded by the caregiver.
As the child becomes rehydrated, vomiting often decreases and larger fluid volumes may be
used.
o If vomiting persists, infusion of oral rehydration solution via a nasogastric tube may be
temporarily used to achieve rehydration. Intravenous fluid administration (20-30 mL/kg of
isotonic sodium chloride 0.9% solution over 1-2 h) may also be used until oral rehydration is
tolerated. According to a Cochrane systematic review, for every 25 children treated with ORT
for dehydration, one fails and requires intravenous therapy.
o Replace ongoing losses from stools and emesis (estimate volume and replace) in addition to
replacing the calculated fluid deficit.
o An age appropriate diet may be started as soon as the child is able to tolerate oral intake.

Severe dehydration
o Laboratory evaluation and intravenous rehydration are required. The underlying cause of the
dehydration must be determined and appropriately treated.
o Phase 1 focuses on emergency management. Severe dehydration is characterized by a
state of hypovolemic shock requiring rapid treatment. Initial management includes placement
of an intravenous or intraosseous line and rapid administration of 20 mL/kg of an isotonic
crystalloid (eg, lactated Ringer solution, 0.9% sodium chloride). Additional fluid boluses may
be required depending on the severity of the dehydration. The child should be frequently
reassessed to determine the response to treatment. As intravascular volume is replenished,
tachycardia, capillary refill, urine output, and mental status all should improve. If
improvement is not observed after 60 mL/kg of fluid administration, other etiologies of shock
(eg, cardiac, anaphylactic, septic) should be considered. Hemodynamic monitoring and
inotropic support may be indicated.

Pharmacologic management
o Antidiarrheal agents are not recommended because of a high incidence of side effects
including lethargy, respiratory depression, and coma.
o Routine empiric antibiotics should be avoided and may worsen some specific diarrheal
disease states (eg, hemolytic-uremic syndrome,Clostridium difficile).
o Over-the-counter antiemetics are not recommended due to side effects including drowsiness
and impaired oral rehydration.
o In an emergency department study, ondansetron has been shown to decrease likelihood of
vomiting, increase oral intake, and decrease emergency department length of stay but has
not shown significant effects on hospitalization rates or long-term outcomes.
[13]

o Dimenhydrinate, although used in Europe and Canada, has not been found to improve oral
rehydration.

FLUID VOLUME EXCESS
Fluid volume excess, or hypervolemia, occurs from an increase in total body sodium
content and an increase in total body water. This fluid excess usually results from compromised
regulatory mechanisms for sodium and water as seen in congestive heart failure (CHF), kidney
failure, and liver failure. It may also be caused by excessive intake of sodium from foods,
intravenous (IV) solutions, medications, or diagnostic contrast dyes. Hypervolemia may be an
acute or chronic condition managed in the hospital, outpatient center, or home setting. The
therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment
to normal. Treatment consists of fluid and sodium restriction, and the use of diuretics. For acute
cases dialysis may be required.
Related Factors
Excessive fluid intake
Excessive sodium intake
Renal insufficiency or failure
Steroid therapy
Low protein intake or malnutrition
Decreased cardiac output; chronic or acute heart disease
Head injury
Liver disease
Severe stress
Hormonal disturbances
Defining Characteristics
Weight gain
Edema
Bounding pulses
Shortness of breath; orthopnea
Pulmonary congestion on x-ray
Abnormal breath sounds: crackles (rales)
Change in respiratory pattern
Third heart sound S
3

Intake greater than output
Decreased hemoglobin or hematocrit
Increased blood pressure
Increased central venous pressure (CVP)
Increased pulmonary artery pressure (PAP)
Jugular vein distention
Change in mental status (lethargy or confusion)
Oliguria
Specific gravity changes
Azotemia
Change in electrolytes
Restlessness and anxiety
Hypervolemia: Pathologic Process
Normally, the body can create processes with which it can compensate and relinquish
fluid and electrolyte equilibrium. This is usually done with the help of hormones such as
aldosterone, atrial natriuretic peptide (ANP) and antidiuretic hormone (ADH). These hormones
cause the nephrons in the kidneys to release the essential water and sodium needed by the
body.
Hypervolemia may occur in instances where there is an elevation of intravascular
volume levels. This may be due to shifts in fluids from the interstitium to plasma, reduced
excretion of sodium and water, excessive intravenous fluids, and excessive retention of water
and sodium from chronic renal stimuli attempting to conserve both.

An elevation of the extracellular fluid volume produces circulatory overload and
subsequently, an abnormally amplified cardiac contractility, increased mean artery pressure
(MAP), and an elevated capillary hydrostatic pressure. The latter, as a consequence, causes
shifts of fluids to the interstitial space, and hence, producing edema.


If severe hypervolemia is at hand, or patient has a previous history if cardiac
dysfunction, compensatory mechanisms may fail. Urinary excretion of sodium and water may
fall short. Antidiuretic hormone and aldosterone may not be diminished from mean arterial
pressure elevation. Hence, pulmonary edema and heart failure may prevail.
Treatment and Management of Hypervolemia

The following are therapeutic interventions in the management of hypervolemia:
Restriction of sodium and water intake. Monitor input of fluids, including that of oral,
enteral and parenteral. Avoid foods with high sodium content.
Diuretics may be given. Loop diuretics, such as furosemide, are recommended for heart
failure and severe hypervolemia.
To assess the severity of electrolyte loss and monitor the patients response to diuresis,
his weight and his urine output must be regularly determined and monitored.
Medications, like nitroglycerin and morphine, can be administered for dilatation of blood
vessels and subsequent reduction of pulmonary congestion.
Hydralazine and Captopril, afterload reduction medications, can also be given for relief
of pulmonary edema
Renal replacement therapies, such as hemodialysis and peritoneal dialysis, may be
performed among patients with renal failure or those with severe hypervolemia.
Continuous arteriovenous and venovenous hemoinfiltrations both aims for sufficient
removal of excess fluids from those patients not necessitating dialysis.
Other palliative measures comprise of antiembolism stockings to mobilize edema,
oxygen inhalation, bed rest, and, of course, treatment of underlying cause of hypervolemia.[5, 6,
7]
Expected Outcome
Patient maintains adequate fluid volume and electrolyte balance as evidenced by: vital signs
within normal limits, clear lung sounds, pulmonary congestion absent on x-ray, and resolution of
edema.