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Judy Sabel BSN RN Alverno College MSN 621.

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Presentation on theme: "Judy Sabel BSN RN Alverno College MSN 621."— Presentation transcript:

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2 Judy Sabel BSN RN Alverno College MSN 621

3  Describe signs and symptoms of fluid volume deficit and fluid volume overload  Identify risk factors, laboratory findings & nursing interventions for patients with fluid imbalance  Recognize the body’s mechanisms involved with fluid maintenance  Identify factors which can affect fluid balance

4  Return to the table of contents by clicking :  The bee signifies a question that will review tutorial content- click on this to answer *Make sure your pointer appears as shown  Navigate forward and backwards by clicking: Table of Contents Table of Contents shape

5 Dehydration Scenario Dehydration Scenario Control of Fluid Balance Control of Fluid Balance Fluid Overload Scenario Fluid Overload Scenario Evaluating Edema Kidney Functions Stress Response, Inflammation & Genetics Stress Response, Inflammation & Genetics Common Laboratory Values Common Laboratory Values H20 Balance Puzzle H20 Balance Puzzle Nursing Interventions Nursing Interventions References *Note all images are microsoft clipart unless otherwise noted

6 Noah Watter a 81 yr. old recent widower was admitted today with dehydration. He was mowing his lawn when his neighbor found him lying on the ground with slurred speech. The outside temperature was 92⁰ with 80% humidity. He has a history of hypertrophic cardiomyopathy and hypertension. You will be his nurse today. iStock_ XSmal Table of Contents Table of Contents

7  Noah is alert and oriented x 3  Temperature 99.8, HR 118, BP 88/60, RR 30  SpO2- 92 on room air, breath sounds clear bilaterally  Skin diaphoretic, capillary refill <3 seconds  Peripheral pulses are thready and 1+  Color is ashen, skin cool and clammy  Skin turgor poor, and tongue is dry  Urine output is decreased Microsoft clipart Table of Contents Table of Contents

8 Capillary refill < 3 seconds SPO 92 on room air Alert and oriented x 3 HR 118, B/P 88/60 Incorrect Table of Contents Table of Contents Incorrect Correct!!

9  Tachycardia is usually the earliest sign of decreased vascular volume.  Blood pressure is related to the amount of blood the heart pumps and the extent of vasoconstriction present. Fluid volume affects these elements, making blood pressure measurement key in assessing a patients fluid status. Table of Contents Table of Contents (Taylor, 2011) (Thompson, 2008)

10 NumberDefinitionDescription 0Absent pulseNo pulsation felt despite extreme pressure 1+Thready pulsePulsation is not easily felt, and slight pressure causes it to disappear 2+NormalStronger than a thready pulse; light pressure causes it to disappear 3+StrongPulsation easily felt, takes moderate pressure to cause it to disappear 4+Bounding pulseThe pulsation is strong and does not disappear with moderate pressure (Taylor, 2011) Table of Contents Table of Contents *When dehydrated your patient’s pulse may be thready.

11  Skin diaphoretic, temperature 99.8  Peripheral pulses are thready and 1+  Color is ashen, skin cool and clammy  Skin turgor (elasticity) poor and tongue is dry  Urine output is low Table of Contents Table of Contents

12  CBC: WBC 7,000/mm³, Hgb 17g/dl, Hct 57%, Platelets 350,000/mm³  Chemistry: Na 162meq/L, K 5.0meq/L, CL 115meq/L, HCO3 15meq/L, BUN 23mg/dl, Creatinine 1.0mg/dl, Glucose 90mg/dl Used with permission by the Washington Endocrine Clinic Table of Contents Table of Contents Click here to view common lab values Click here to view common lab values

13 HCT 57% and Na 162 K+ 5.0 WBC’s -7,000 Glucose 90 Incorrect Correct!! Table of Contents Table of Contents

14  Increased HCT – higher proportion of RBC compared to water in the blood. 57% means that a 100ml sample contains 57ml of packed RBC’s.  Increased electrolytes-elevated serum sodium level (above 145mEq/L). If more water is lost than NA+, serum sodium may be high.  High urine specific gravity result of renal vasoconstriction and increased secretion of ADH and aldosterone.  Increased BUN- reflects kidney’s decreased excretion of urea.  Low urine output & concentrated urine. (Eckman 2008 ) (Pagana 2006) Table of Contents Table of Contents

15 The elderly have a lower proportion of water in their bodies The elderly have decrease in kidney function, thirst sensation, and functional sweat glands He was mowing his lawn in 90⁰ weather All of the above Table of Contents Table of Contents Incorrect Correct!! Incorrect

16  Lack significant fluid reserves  Lack ability to conserve fluid quickly  Watch for changes in mental status (Ackley 2006)  Prevalence of acute and chronic diseases makes them more susceptible to fluid imbalances  Skin may lack elasticity in the elderly skin turgor may be an unreliable sign  Check skin turgor of the elderly client on the forehead, sternum or inner thigh  Presence of longitudinal furrows (deep grooves on tongue) or dry mucous membranes is a good indication of dehydration Table of Contents Table of Contents (Woodrow 2002) Used with permission from Pethum Madusanka

17 Monitoring vital signs and cognitive function Providing frequent oral hygiene and mucous membrane assessment Placing a urinary catheter to assess intake and output Daily weights Table of Contents Table of Contents Incorrec t Correct!! Incorrect

18 **It is especially important to monitor elderly clients for excess fluid volume during the treatment of dehydration:  Listen for adventitious lung sounds  Assess for edema  Monitor vital signs  Monitor daily weights (Ackley, 2006 ) Table of Contents Table of Contents

19  Removes wastes and water from the blood  Balances chemicals in the body  Release of hormones  Helps to control blood pressure  Helps to produce red blood cells  Activates vitamin D Table of Contents Table of Contents Click screen to view video!

20 1. Intracellular (ICF)- inside the cells. 2. Extracellular (ECF)- outside the cells Broken down further: Intravascular fluid or plasma 25% Interstitial fluid-surrounds the cells 75% Infants have a greater percentage of body water stored inside interstitial spaces compared to adults. Many older people have less muscle but more fat and so have fewer water stores. Table of Contents Table of Contents

21 Entering (ml)Losses (ml) Liquids1200ml Urine1400ml Solid foods1000ml Feces 200ml Cell metabolism 300ml Insensible losses Lungs 400ml Skin 500ml Total2500ml (Gould, 2011 ) Table of Contents Table of Contents *Insensible losses can’t be measured or seen.

22  Sodium-promotes water retention. Water follows sodium. *Maintains the osmotic pressure of extracellular fluid *Regulates renal retention and excretion of water *Maintains systemic blood pressure  Albumin-(magnet) for water. Water follows albumin. Large molecule which draws fluid to it - keeping fluid in the vascular space. This is called plasma colloid osmotic pressure. (Eckman, 2008) Table of Contents Table of Contents

23  Thirst mechanism in the hypothalamus.  Kidneys- filter electrolytes, wastes & water into urine.  Hormonal systems-  Antidiuretic hormone (ADH)- Also known as vasopressin. Produced by the hypothalamus.  Renin- from the kidneys activates the renin-angiotensin- aldosterone (RAA) system.  Atrial natriuretic peptide ANP-produced and stored in the atria of the heart.  Brain natriuretic peptide BNP-secreted from the cardiac cells. Table of Contents Table of Contents (Eckman, 2008)

24 The hypothalamus senses low blood volume and signals the pituitary gland. Pituitary gland secretes ADH into bloodstream ADH causes kidney to retain water Water retention boosts blood volume and decreases serum osmolality. (Eckman, 2008) Table of Contents Table of Contents Holds water when fluid levels drop and releases it when fluid levels rise

25 . Blood flow to the kidney decreases Kidney secretes renin into the bloodstream Renin converts angiotensinogen formed in the liver to antiotensin I Angiotensin II stimulates the adrenal glands to produce aldosterone Angiotensin 1 is converted to angiotensin II Aldosterone causes the kidneys to retain sodium and water Sodium and water retention leads to increases in fluid volume and sodium levels (Eckman, 2008) Table of Contents Table of Contents

26  When blood volume and blood pressure increase the heart’s ANP & BNP shut off the renin-angiotensin-aldosterone system, which stabilizes blood volume and blood pressure. Na+ and water will be lost in the urine BP. BP (Eckman, 2008) Table of Contents Table of Contents

27 True False Table of Contents Table of Contents Correct!! Incorrect

28  Because his body was dehydrated, it would try to retain as much fluid as possible (Like a dam)  To retain fluid, ADH secretion increases ADH Table of Contents Table of Contents Click on arrow

29 Secreting renin Producing aldosterone Slowing the release of ADH Secreting ANP Incorrect Correct!! Table of Contents Table of Contents

30  Aldosterone is produced by the adrenal glands  Pituitary gland secretes ADH  ANP is produced and stored in the atria of the heart Table of Contents Table of Contents

31 Noah Watter a 81 yr. old recent widower was admitted today with dehydration. He has a history of hypertrophic cardiomyopathy and hypertension. You will be his nurse today. Noah’s physician orders the following treatments: iStock_ XSmal Table of Contents Table of Contents  IV Fluids  Daily CBC, electrolytes, BUN and creatinine levels  Orthostatic blood pressures daily a 15mm Hg drop in blood pressure when upright or an increase of 15 beats/min in pulse rate is seen with dehydration

32 Your Nursing Assessment  Temperature 98.6, HR 70, BP 180/90, RR 32  Skin pale, +2 pedal edema  Lung sounds have bilateral rales & patient coughing  Bounding pulses 4+  Urine output 500ml  Noah asks for you to call his wife “I’m having problems breathing.” Table of Contents Table of Contents

33 Noah is now fluid overloaded Noah is showing s/s of pneumonia Noah has adequate tissue perfusion Noah needs to be transferred to the ICU Incorrect Correct!! Table of Contents Table of Contents

34  BP increased to 180/90 is the result of excess volume- blood contains more water than normal, increasing the pressure on the blood vessels  Shortness of breath, rales and cough- as left side of the heart becomes overloaded fluid backs up into the lungs  Pulse amplitude is increased in fluid volume excess  Change in mental status is often seen in the elderly (Taylor, 2011 ) Table of Contents Table of Contents

35  As left side of the heart becomes fluid overloaded and pump efficiency declines, fluid backs up into the lungs.  Patient is SOB, tachypneic, cough  You may hear rales on auscultation of the lungs Hydrostatic pressure forces fluid out of pulmonary blood vessels Interstitial Space When amount of fluid is excessive, fluid is forced into the aveoli resulting in pulmonary edema (Eckman 2008) Click lungs 3 times! Table of Contents Table of Contents

36  Discontinue IV fluids  Chest X ray stat  CBC, electrolytes, BUN, Creatinine & UA stat Results: CBC: WBC 8,000/mm³ Hgb 19g/dl, Hct 36%, Platelets 350,000/mm³ Chemistry: Na 135meq/L, K 3.2meq/L CL 115meq/L, HCO3 15 meq/L BUN 5, Creatinine 0.5mg/dl, Glucose 88  Give 40mg Lasix IVP now.  Give K-Dur 20 Meq PO BID  Oxygen at 2L Table of Contents Table of Contents Click here to view common lab values Click here to view common lab values

37 BUN 5mg/dl and Creatinine 0.5mg/dl Hct 36% K+ 3.2meq/dl All of the above Incorrect Correct! Incorrect Table of Contents Table of Contents

38  Hct, serum potassium and BUN levels are low due to hemodilution.  Lower proportion of RBC compared to water in the blood. ***Very important to monitor K+ levels especially when receiving Lasix (potassium depleting diuretic) (Eckman 2008) Table of Contents Table of Contents

39  Usually body compensates and restores fluid balance (hormones)  If patient has poor heart function the body can’t compensate for the extra volume (will see increased BP)  Fluid is forced out of the blood vessels and moves into the interstitial space causing edema of the tissues (Eckman, 2008) Table of Contents Table of Contents

40  Edema results as hydrostatic (fluid pushing) pressure builds in the vessels, forcing fluid into the tissues  Skin looks puffy and feels cool, pits when touched  Patient gains weight (each 17oz.of fluid= 1lb)  If area is palpated with the fingers an indentation may remain after the pressure is released  Daily weights  Visual assessment  Measurement of affected part 0No edema +1 Trace 2mm +2 Moderate 4mm +3 Deep 6mm +4 Very Deep 8mm (Taylor, 2011) Table of Contents Table of Contents

41  Body’s attempt to adapt to stimuli  Hormones and neurotransmitters that are released during the stress response function to: 1. Alert individual to a threat to homeostasis 2. Enhance cardiovascular and metabolic activity in order to manage stressor 3. Focus energy of the body by suppressing the activity of systems not immediately needed (Porth 2009) Click “stress” to view video! Table of Contents Table of Contents

42  Sympathetic nervous system- (fight or flight response) SNS Adrenal medulla Epinephrine & Norepinephrine Increased heart rate Increased blood pressure Pupil dilation Dry mouth Increased blood coagulability Activates the RAA system ADH- also known as vasopressin increases water retention by the kidneys and produces vasoconstriction of blood vessels Corticotropin releasing factor (CRF )increases ACTH which increases cortisol & aldosterone (Porth 2009) Click face 4 times! Table of Contents Table of Contents

43 Click on the ball to see the how the inflammatory response can lead to decreased blood volume and edema Increased capillary permeability Exudate leaks out of capillaries into tissues (Bowne, 2011) (Porth, 2011) Table of Contents Table of Contents Tissue Damage Damaged cells release prostaglandins and leukotrienes Damaged cells release prostaglandins and leukotrienes Hypovolemia ( decreased blood volume) Edema of tissues Click 8 times!

44  Your patient, Noah Watter has a history of Hypertrophic cardiomyopathy (HCM). This is an autosomal dominant heart disease caused by mutations in the genes encoding proteins of the cardiac muscle. These mutations impact his heart function which can negatively impact his ability to maintain fluid balance. His heart is affected in following ways: Left ventrical hypertrophy Disproportionate thickening of the ventricular septum Abnormal diastolic filling Cardiac arrhythmias (Porth 2009) Table of Contents Table of Contents

45 Table of Contents Table of Contents Nephronophthisis -medullary cystic disease complex Nephronophthisis -medullary cystic disease complex Ren -Related Kidney Disease Ren -Related Kidney Disease Hypoaldosteronism Joubert Syndrome Polycystic Kidney Disease Polycystic Kidney Disease Alport Syndrome The following are genetic conditions affecting the kidneys. Place mouse over condition for definition! (Porth, 2011) (Venes, 2009)

46 Assess for presence or worsening of FVD Administer oral fluids if indicated If patient unable to eat and drink, anticipate TPN or tube feedings to be ordered Monitor patient’s response to fluid intake, either oral or parenteral Be alert for signs of fluid overload Provide appropriate skin care Table of Contents Table of Contents (Taylor, 2011)

47 Assess for presence or worsening of FVE Encourage adherence to sodium- restricted or fluid restricted diet if ordered Avoid OTC drugs or check with physician or pharmacist about sodium content Encourage rest periods Monitor patient’s response to diuretics Teach self-monitoring of weight and intake and output Attentive skincare Monitor respiratory status Table of Contents Table of Contents (Taylor, 2011)

48 Click on puzzle piece! Table of Contents Table of Contents

49 (Pagana, 2006) Table of Contents Table of Contents Click here to return to dehydration scenario Click here to return to dehydration scenario Click here to return to fluid overload scenario Click here to return to fluid overload scenario

50 References Benelam, B. (2010). Recognizing the signs of dehydration. Practice Nursing, 21(5), Bowne, P. (2011). Pat Bowne’s patho. Retrieved from Eckman, M., Lavine, J., & Thompson, G. (eds). (2008). Fluids & electrolyes made incredibly easy. Lippincott. Gould, B. E., & Dyer, R. M. (2011). Pathophysiology for the health professions. Saunders Elsevier. Licastro, F., Candore, G., Lio, D., Porcellini, E., Colonna-Romano, G., Franceschi, C. et al. (2005, May). Innate immunity and inflammation in ageing; a key for understanding age-related diseases. Immunity & Aging, 2(8), Moorhead, S., Johnson, M., Mass, M. L., & Elizabeth, S. (eds). (2008). Nursing outcomes classification (NOC). Mosby. Pagana, K., & Pagana, T. (2006). Mosby's manual of diagnostic and laboratory tests (third edition). Mosby. Porth, C. M., & Matfin, G. (2009). Pathophysiology concepts of altered health states. Lippincott. Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing the art and science of nursing care. Lippincott. Venes, D. (eds). (2009) Tabers cyclopedic medical dictionary. 21 edition. F.A. Davis. Woodrow, P. (2003). Assessing fluid balance in older people: Fluid replacement. Nursing Older People, 14(10), Table of Contents Table of Contents


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