HYPERVOLEMIA Pathophysiology With a fluid volume excess, the hydrostatic pressure of the fluid is higher than the usual

arterial end of the capillary, pushing excess fluids into the interstitial spaces. The fluid is not re-absorbed at the venous end of the capillary because of the oncotic pressure is too low to pull the fluid back across the capillary membrane. Usually the residual fluids are removed by the lymphatics, but in the case of edema, the fluid volume overload the lymph system and stays in the interstitial space leading to peripheral edema. The process of edema can be progressive. As the fluid pressure increases in the interstitial area and tissues, it creates a resistance to forward blood flow and increases resistance throughout the circulatory system. This process is called increased peripheral vascular resistance and eventually it creates a gradient that resists left ventricular output. Blood is unable to be propelled forward and it backs up across the alveocapillary membrane of the lungs, resulting in pulmonary edema. Because of the lungs are low pressure organs, they also offer little resistance to fluid accumulation. Pulmonary edema develops quickly in clients with distention of the left side of the heart muscle in those person who have an impaired myocardial pump. If the right side of the heart fails, peripheral edema occurs through the same retrograde process. Left-sided heart failure may lead to the right-sided failure and vice versa. Therefore pulmonary and peripheral edema may exist simultaneously.

Nursing Diagnosis Excess fluid volume

Clinical Manifestations
The excess fluid, primarily salt and water, builds up in various locations in the body and leads to an increase in weight, swelling in the legs and arms (peripheral edema), and/or fluid in the abdomen (ascites). Eventually, the fluid enters the air spaces in the lungs, reduces the amount of oxygen that can enter the blood, and causes shortness of breath (dyspnea), coughing, crackles, pallor, and cyanosis Fluid can also collect in the lungs when lying down at night, possibly making nighttime breathing and sleeping difficult (paroxysmal nocturnal dyspnea). Cardiovascular manifestations such as jugular vein distention, peripheral vein filling more than 5 seconds, bounding pulse, elevated blood pressure, increased CVP and PCWP, an extra S3 can be auscultated.

Laboratory Findings Plasma osmolality less than 275 mOsm/Kg Plasma sodium less than 135 mEq/L Hematocrit less than 45% Specific gravity less than 1.010 BUN less than 8mg/dl

Nursing Management 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Monitor clients vital signs for bounding pulse, elevated blood pressure, or both Assess apical pulse if the radial pulse is irregular. Assess breath sounds every 4-8 hours for crackles in the bases of the lungs, ronchi or wheezes Assess for changes in respiratory effort with activity or rest. Assess for skin integrity edematous skin is fragile and is at risk for injury. Compare I and O. Weigh client daily before breakfast. Measure edematous area if pronounced such as extremities or abdomen. Monitor laboratory findings. Observe for changes in the level of consciousness.

HYPOVOLEMIA

Pathophysiology
Hypovolemia is a decrease in the volume of blood in your body, which can be due to blood loss or loss of body fluids. Blood loss can result from external injuries, internal bleeding, or certain obstetric emergencies. Diarrhea and vomiting are common causes of body fluid loss. Fluid can also be lost as a result of large burns, excessive perspiration, or diuretics. Inadequate fluid intake can also cause hypovolemia. At the onset of hypovolemia, the mouth, nose, and other mucous membranes dry out, the skin loses its elasticity, and urine output decreases. Initially, the body compensates for the volume loss by increasing the heart rate, increasing the strength of heart contractions, and constricting blood vessels in the periphery while preserving blood flow to the brain, heart and kidneys. With continuing volume loss, the body loses its ability to compensate and blood pressure drops. At this point, the heart is unable to pump enough blood to vital organs to meet their needs and tissue damage is likely to occur.

Nursing Diagnosis Deficient fluid volume Impaired oral mucous membrane Risk for Injury

Clinical Manifestations Symptoms may include cold, clammy skin, paleness, rapid breathing and heart rate, weakness, decreased or absent urine output, sweating, anxiety, confusion, and unconsciousness. Weight loss, thirst, Laboratory Findings Osmolality greater than 295 mOsm/Kg Plasma sodium greater than 145 mEq/L BUN greater than 25mg/dl Plasma glucose greater than 120 mg/dl Hematocrit greater than 55% Specific gravity greater than 1.030

Nursing Management 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Monitor clients vital signs every 2-4 hours. Assess for postural blood pressure and pulse changes. Assess for peripheral vein filling. Record I and O accurately. Weigh client daily before breakfast. Monitor laboratory findings. Observe for changes in the level of consciousness. Assess oral cavity between the gums and cheek for dryness and longitudinal furrows. Note any speech and swallowing difficulty Check skin turgor. Keep fresh water or other fluids in an easy accessible location. Try to provide fluid every 1-2 hours. Provide oral care every 2 hours. Report diarrhea, excessive sweating or rapid breathing