Excessive intake of Na, Alka-seltzer, hypertonic enemas-makes body retain water
Excessive irrigation of body cavities or organs
Aggressive fluid replacements
What assessment findings would you expect to find in a pt. with hypervolemia?
Intake > output
Full bounding pulses
What is edema?
Increased water and sodium content in interstitial and intravascular spaces. Caused by increased capillary hydrostatic pressures, decreaed oncotic pressures (decreased albumin, malnutrition), or increased capillary permeability (trauma)
A pt. comes into the ER with anasarca. What would you expect to find?
Severe edema all over the patient's body.
What are the goals for hypervolemia?
Maintain fluid balance
Prevent respiratory (pulmonary edema) and cardiovascular complications (CHF)
Eliminate cause of overload
What are interventions for hypervolemia?
Assess for s/sx of overload
Monitor daily weight, vs, I/O (hourly)
Assess and document edema
Assess breath sounds/pulse ox/heard sounds (S3)
Fluid restrictions/Na restrictions
Diuretics as ordered
T or F
A client with hypervolemia needs to report to the doctor if they have a change in weight.
What is dehydration?
Water lost fromt he body without significant loss of electrolytes causing increased serum osmolality and increased serum Na levels. Water is drawn into the intravascular space from the cells=cellular dehydration.
What causes dehydration?
Decreased water intake
Decreasd thirst sensation
Enteral feedings w/o sufficient water intake
High risk:infants, confused/comatose, elderly, brain injury, inadequate production of ADH
What assessment findings would you expect to find in a pt. with dehydration?
Poor turgor (Not reliable in elderly)
Decreased urine output
Increased HR with falling BP
What interventions would you perform on a pt. with dehydration?
Assess vs, weight, turgor, neck and hand vein filling, mucous membranes, bowel/breath sounds
Monitor daily weight
Admin. fluids-isotonic NS or LR or hypotonic fluids----gradual
Monitor LOC, orientation and seizure precautions-for hypernatremia
Assist with mobility-positioning (orthostasis)
Safety and skin/mouth care
What is overhydration?
Water intoxication. Water is gained in excess of electrolytes causing low serum osmolality and low serum Na levels. Water is drawn in to cells causing them to swell. Can lead to cerebral edema, impaired neuro function and death!!!
What causes overhydration?
Fluids and electrolytes lost at equal balance but only water is replaced
Syndrome of inapporpriate ADH (SIADH)-body holds water
Milignant tumors, aids, head injury, drug admin (anesthetics, barbs-urinary retention)
What assessment findings would you expect to find in a pt with overhydration?
Low Na levels leading to changes in LOC, disorientation, seizures
Increased intracranial pressures-initially headaches-late signs are pupil changes, bradycardia, and wide pulse pressure
What interventions would you expect to perform on a pt. with overhydration?
Assess LOC, orientation and monitor for seizures (Neuro checks)
Limit water intake-fluid restriction 500cc/day
Allow sodium in diet, salt shaker at bedside
Irrigate with saline-no tap water irrigations, flushes, enemas