■ Fluid volume deficit related to high-solute tube feedings
■ Altered oral mucous membrane related to dehydration
■ Altered tissue perfusion: Cardiopulmonary, renal, and peripheral related to hypovolemia
■ Risk of injury related to altered sensorium and/or dizziness
■ Knowledge deficit related to risk factors and therapeutic interven-tions
Nursing Management
1. Monitor specific assessment parameters related to management of FVD including:
a. Fluid status, including intake and output b. Specific gravity
c. Trends of daily weights
d. Hemodynamic status (central venous pressure when appro-priate)
e. Signs of dehydration: Skin turgor, delayed capillary refill, weak or thready pulse, severe thirst, dry mucous membranes, decreased urine output, and hypotension
2. Monitor fluid loss (e.g., bleeding, vomiting, diarrhea, and per-spiration tachypnea).
3. Administer isotonic solutions for extracellular rehydration, if appropriate.
4. Administer hypotonic solutions for intracellular rehydration, if appropriate.
5. Monitor laboratory data:
a. Hemoglobin and hematocrit b. Serum sodium levels
c. Serum osmolarity
d. Blood urea nitrogen (BUN) e. Serum electrolytes
6. Encourage oral fluid intake.
7. Promote skin integrity.
8. Provide comfort measures:
a. Good oral hygiene (rinse with equal parts of peroxide and water)
b. Avoid glycerin and lemon or alcohol-based mouthwashes, which can be drying.
c. Avoid sucking on hard candy or chewing gum, both of which can further dry oral mucous membranes.
d. Apply lip moisturizer.
e. Apply skin moisturizer.
(Continued on following page)
9. Listen to client’s concerns, answer questions, and implement teaching.
10. Implement measures to control nausea, vomiting, diarrhea, and high fever.
11. Administer medication therapy according to orders:
a. Antiemetics to prevent fluid losses due to nausea and vomiting
b. Antidiarrheals to prevent fluid losses for the GI tract c. ADH vasopressin used to corrrect diabetes insipidus
d. Antipyretics used to control fever and minimize fluid losses.
Sources: Sparks & Taylor (1998), Hogan & Wane (2003), Metheny (2000).
Teach patient risk factors for development of FVD or FVE.
Explain to client and family the reasons for intake and output records.
Teach the client to keep track of oral liquids consumed.
Assess patient’s understanding of the type of fluid loss being experienced.
Give verbal and written instructions for fluid replacement (drink at least 3 quarts of liquid).
Teach to increase the fluid intake during hot days, in the presence of fever or infection and to decrease activity during extreme weather.
Teach how to observe for dehydration (especially in infants).
Instruct to seek medical consultation for continued dehydration.
Teach appropriate use of laxatives, enemas, and diuretics.
Inform patient to notify physician if he or she has excessive edema or weight gain (more than 2 lbs) or increased shortness of breath.
Provide literature concerning low-salt diets; consult with dietitian if necessary.
Provide dietary education.
Teach to avoid adding salt while cooking.
Teach to avoid caffeine because it acts as a mild diuretic.
Patient Education
Consider home care visit to follow up with patients with diabetes mellitus, car-diovascular disorders, and severe GI disorders.
Follow up with home care for patients taking drug therapy (diuretics) for edema.
Consider home care visit to follow up on diet and instructions on use of pressure stockings.
Home Care Issues
■ Fluid is distributed in three compartments: intracellular (40 percent), intravascular (5 percent), and interstitial (15 percent); total body weight in water is 60 percent for an average adult.
■ Fluid is transported passively by filtration, diffusion, and osmosis.
■ Electrolytes are actively transported by ATP on cell membranes and the sodium–potassium pump.
■ Osmosis is the movement of water from a lower concentration to a higher concentration across a semipermeable membrane.
■ The osmolarity of I.V. solutions has the following ranges:
■ Isotonic solutions: 250 to 375 mOsm/L
■ Hypotonic solutions: less than 250 mOsm/L
■ Hypertonic solutions: greater than 375 mOsm/L
■ The homeostatic organs that regulate fluid and electrolyte balance include the kidneys; heart and blood vessels; lungs; and adrenal, parathyroid, and pituitary glands
■ There are six areas to assess for fluid balance: neurologic status, cardio-vascular, respiratory, integumentary, special senses, and body weight
■ Fluid imbalances fall into two categories:
■ Fluid volume deficit caused primarily by disorders of the GI system;
signs and symptoms reflect a dehydrated individual. Treatment is aimed at rehydration with isotonic sodium chloride.
■ Fluid volume excess caused primarily by cardiovascular dysfunction, renal or endocrine dysfunction, and too-rapid administration of I.V.
fluids; signs and symptoms reflect fluid overload. Treatment is aimed at decreasing the sodium level, using diuretics to increase the excre-tion of fluids, and treating the underlying cause.
■■ Critical Thinking: Case Study
A 28-year-old woman was admitted to the hospital after 3 days of severe diarrhea and poor intake. She weights 120 lbs on admission (preillness weight, 132 lbs). Her BUN was 40 mg/dL and serum creatinine was 1.3 mg/dL, potassium was 3.2 mEq/mL, sodium 133 mEq/mL. Skin turgor was poor and urine output was 15 mL/h (specific gravity 1.030). Blood pressure was 120/80 mm Hg recumbent and fell to 98/60 mm Hg when erect. Pulse was 110, weak and regular.
What percent of body weight did she lose? What concerns would the nurse have regarding her laboratory work? What nursing diagnoses would apply to this woman? What I.V. fluids would you anticipate the physician to order? What nursing interventions would be implemented?
Media Link: Use the enclosed CD–ROM for more critical thinking activities, and the answers to this case study.
Key Points
Post-Test
1. A solution of 5 percent dextrose and 0.9 percent NaCl has an osmo-larity of 559. By administering this, you know that fluid will move from the ____ space to the ___ space.
a. Intracellular, vascular b. Vascular, interstitial
c. Interstitial, cellular
2. A solution of 0.45 percent NaCl has an osmolarity of 154. By administering this, you know that fluid will move from the ___
space to the ___ space.
a. Intracellular, vascular b. Vascular, intracellular
c. Interstitial, cellular
3. Lactated Ringer’s solution has an osmolarity of 273. By adminis-tering this, you know that fluid will:
a. Move from the intracellular space to the vascular space.
b. Move from the vascular space to the cellular space.
c. Stay in the vascular space.
4. Water is transported passively by:
a. Diffusion b. Osmosis
c. Filtration d. All of the above
5. You have just completed a physical assessment of a 68-year-old man. He knows who he is but is unsure of where he is (previous orientation normal). His eyes are sunken, his mouth is coated with an extra longitudinal furrow, and his lips are cracked. Hand vein filling takes more than 5 seconds, and tenting of the skin appears over the sternum. His vital signs are blood pressure of 128/60 mm Hg, pulse of 78, and respiratory rate of 16 (previously 150/78, 76, 16, respectively). Your assessment would lead you to suspect:
a. Fluid volume deficit b. Fluid volume excess
6. If the external temperature is 101⬚F, which of the following age groups is at highest risk for fluid volume deficit?
a. Infants
b. School-age children c. Adolescents d. Middle-aged adults
7. All of the following could be the etiology for a nursing diagnosis of fluid volume excess EXCEPT:
a. Excessive infusion of 0.9 percent sodium chloride solution b. Suppression of parathyroid function
c. SIADH
d. Congestive heart failure
8. Which of the following lab values are consistent with fluid vol-ume deficit?
a. Urine specific gravity 1.010 b. Blood urea nitrogen 6
c. Hemoglobin 13
d. Serum osmolarity 305 mOsm/kg
9. All of the following conditions produce excess antidiuretic hor-mone EXCEPT:
a. Head trauma b. Anesthesia
c. Ovarian cancer d. Brain tumor
10. All of the following should be part of a focused assessment if a patient presents with peripheral edema EXCEPT:
a. Assessment of cardiovascular system b. Laboratory assessment of specific gravity
c. Assessment of respiratory system d. Laboratory assessment of blood sugar
Media Link: Use the enclosed CD–ROM for more practice questions, answers, and rationales.
References
Adelman, R.D., & Solhung, M.J. (1996). Pathophysiology of body fluids and fluid therapy. In Behrman, R.E., Kliegman, R.M., & Arvin, A.M. (eds.). Nelson’s Textbook of Pediatrics (15th ed.). Philadelphia: W.B. Saunders, pp. 185–222.
Craven, R.F, & Hirnle, C.J. (2003). Fundamentals of Nursing: Human Health and Function (4th ed.). Philadelphia: Lippincott-Williams & Wilkins, pp. 910–938.
Giger, J.N., & Davidhizar, R.E. (1999). Transcultural Nursing: Assessment and Intervention. St. Louis: Mosby.
Guyton, A.C., & Hall, J.C. (2000). Textbook of Medical Physiology (10th ed.).
Philadelphia: W.B. Saunders, pp. 110–114.
Hogan, M.A. & Wane, D. (2003). Fluids, Electrolytes, and Acid–Base Balance: Reviews and Rationales. Upper Saddle River, NJ: Prentice-Hall, pp. 17–27.
Hudak, C.M, Gallo, B.M., & Morton, P.G. (1998). Critical Care Nursing: A Holistic Approach. Philadelphia: Lippincott-Williams & Wilkins, pp. 544–547.
Lee, C.A., Barrett, C., & Ignatavicius, D.D. (1996). Fluid and Electrolytes: A Practical Approach (4th ed.). Philadelphia: F.A. Davis.
Levin, E.R., Gardner, D.G., & Samson, W.K. (1998). Natriuretic peptides. New England Journal of Medicine, 339(5), 321–328.
Metheny, N.M. (2000). Fluid and electrolyte balance. In Metheny N.M. (ed.).
Nursing Considerations (4th ed.). Philadelphia: Lippincott-Williams & Wilkins.
National Student Nurses Association, Inc. (1997). Fluids and Electrolytes. Albany, NY: Delmar.
Sparks, S.M., & Taylor, C.M. (1998). Nursing Diagnosis Reference Manual (4th ed.).
Springhouse, PA: Springhouse Corporation.