Fluid Overload (Hypervolemia) Overview

Fluid Overload (Hypervolemia)

• Causes
  • Heart failure
  • Kidney injury
  • Liver cirrhosis
  • Excessive salt intake
  • Excessive administration of sodium-containing fluids in patients with impaired regulatory mechanisms
• Clinical Manifestations
  • Edema
  • Distended neck veins
  • Puffy eyelids
  • Crackles
  • Weight gain
  • Hypertension
  • Bounding pulse
  • Tachypnea, dyspnea
  • Increased urine output; dilute urine
• Medical Management
  • Low sodium diet
  • Diuretics
    • Thiazide diuretics for mild to moderate hypervolemia
    • Loop diuretics for severe hypervolemia
  • Potassium supplementation to prevent hypokalemia while on diuretics
  • Dialysis for severe renal impairment
• Nursing Management
  • Monitor I&O as ordered
  • Weigh daily, watch for rapid weight gain (1 kg = 1 L of fluid)
  • Monitor breath sounds especially if with IV therapy
  • Monitor for presence of edema
    • Feet and ankles for ambulatory patients
    • Sacral area for bedridden patients
  • Encourage bed rest - favors diuresis
  • Regulate IV fluids as prescribed
  • Place patient in semi-Fowler's position if with dyspnea
  • Reposition at regular intervals to prevent pressure ulcers
  • Emphasize the need to read food labels
  • Instruct patient to avoid foods high in sodium
  • Encourage use of seasoning substitutes such as lemon juice, onions, and garlic

Sodium Imbalances

• Normal Serum Concentration: 135-145 mEq/L
• Functions
  • Controls body water distribution
  • Establishes the electrochemical state necessary for muscle contraction and nerve impulse transmission

Hyponatremia

• Serum Sodium Level: < 135 mEq/L
• Causes
  • Vomiting, diarrhea, gastric suctioning
  • Medications: diuretics, lithium, cisplatin, heparin, NSAIDs
  • Decreased aldosterone (Addison’s disease)
  • Water intoxication
  • CHF
  • Chronic renal failure
• Develops when:
  • There is too much water relative to the amount of sodium
  • Too little sodium relative to the amount of water
• Medical Management
  • Sodium replacement
    • Sodium-rich diet for those who can eat and drink
    • NaCl tablets
    • PLR or PNSS IV infusion for those who cannot take sodium by mouth
  • Water restriction
    • Indicated for hyponatremic patients with normal or excess fluid volume
  • Hypertonic saline solution
    • Indicated for severe hyponatremia
  • Drug Therapy: AVP receptor antagonists “vaptans”
    • Mechanism of Action: Act on AVP receptors in the renal tubules to promote aquaresis
    • Conivaptan HCl (Vaprisol) IV - hospitalized patients with moderate to severe hyponatremia
      • Contraindications (C/I): seizure, delirium, coma
    • Tolvaptan (Samsca) - oral medication for clinically significant hypervolemic and euvolemic hyponatremia
• Nursing Management
  • Monitor I&O and daily weights
  • Monitor laboratory values
  • Monitor the progression of manifestations
  • For patients who are able to consume by mouth, encourage foods and fluids with high sodium content
    • Broth made with one beef cube (900 mg)
    • 8 oz of tomato juice (700 mg)
  • Administer IV fluids, as prescribed
  • Watch for signs of circulatory overload: cough, dyspnea, puffy eyelids, dependent edema, excessive weight gain in 24 hours, crackles
  • Institute safety precautions: Keep side rails up, supervise ambulation

Hypernatremia

• Serum Sodium Level: > 145 mEq/L
• Causes: “MODEL”
  • M - Medications, meals
  • O - Osmotic diuretics
  • D - Diabetes insipidus
  • E - Excessive water loss
  • L - Low water intake
• Clinical Manifestations
  • Extreme thirst - first sign
  • Dry, sticky mucous membranes
  • Oliguria
  • Firm, rubbery turgor
  • Red, dry, swollen tongue
  • Restlessness, tachycardia, fatigue
  • Disorientation, hallucination
• Medical Management
  • Safety Alert! Serum sodium correction should be done gradually - too rapid reduction in sodium level renders the plasma temporarily hypo-osmotic to the brain tissue
  • Treat underlying cause
  • Sodium correction
    • Hypotonic electrolyte solution - first line
      • IV of choice: 0.3% NaCl
    • Isotonic non-saline solution - second line
      • D5W - indicated when water needs to be replaced without sodium
• Nursing Management
  • Provide oral fluids at regular intervals
  • Restrict sodium in the diet, as prescribed
  • Monitor behavioral changes
  • Promote safety
  • Monitor intake and output

Potassium Imbalances

• Normal Serum Concentration: 3.5 to 5 mEq/L
• Functions
  • Maintains ICF volume
  • Neuromuscular excitability
  • Regulates contraction and rhythm of the heart

Hypokalemia

• Serum Potassium Level: < 3.5 mEq/L

Hyperkalemia

• Serum Potassium Level: > 5 mEq/L
• Causes: “CARED”
  • C - Cellular movement of K+ from ICF to ECF
  • A - Addison’s disease (hypoaldosteronism)
  • R - Renal failure
  • E - Excessive K+ intake
  • D - Drugs (Spironolactone, ACE inhibitors, NSAIDs)
• Clinical Manifestations: “MURDER”
  • M – Muscle weakness (late sign)
  • U – Unable to calm down (irritability, anxiety)
  • R – Respiratory failure (secondary to muscle weakness)
  • D – Decreasing cardiac contractility (tachycardia →bradycardia)
  • E – Early sign: muscle twitch/cramps
  • R – Rhythm abnormalities: Tall, peaked T waves and prolonged PR interval (most dangerous)
• Medical Management
  • Obtain ECG to detect changes
  • Potassium restriction (diet and medications)
  • Calcium gluconate IV
    • Emergency management for extremely high K+ levels
    • Mechanism of Action: Calcium antagonizes the action of hyperkalemia on the heart but does not lower serum K+ level
    • Side effects: hypotension, bradycardia
  • Sodium polystyrene sulfonate (Kayexalate)
    • Cation exchange resin
    • Administered via PO or retention enema
    • Mechanism of Action: Increases fecal potassium excretion through binding of potassium in the lumen of the gastrointestinal tract. C/I: paralytic ileus
  • Hyperkalemia protocol
    • Regular insulin IV + D50W - causes temporary shift of potassium into the cells
    • Beta-2 agonist (Salbutamol)
      • Nebulized
      • Mechanism of Action: Moves potassium into cells
      • Side effects: tachycardia, chest discomfort
  • Dialysis
• Nursing Management
  • Monitor I&O and closely monitor signs of muscle weakness and dysrhythmias
  • Monitor vital signs, use apical pulse
  • Administer medications, as prescribed
  • Encourage patient to strictly adhere to potassium restriction.
  • Avoid fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa
  • Caution patients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-sparing diuretics

Calcium Imbalances

• Location: Primarily in bones and teeth, the rest can be found circulating in the serum
• Functions
  • Bone mineralization
  • Stabilizes the resting membrane potential of neurons thereby preventing their spontaneous activation
  • Regulation of muscle contraction - causes actin and myosin filaments to slide into each other
  • Cardiac contractility and conduction
• Types of Calcium
  • Ionized calcium
  • Protein-bound calcium
  • Calcium complexed to anions
• Normal Values:
  • Ionized calcium: 4.5 to 5.1 mg/dL
  • Total calcium: 8.5 to 10.5 mg/dL

Hypocalcemia

• Serum Calcium Level: < 8.5 mg/dL
• Causes
  • Primary Hypoparathyroidism
  • Surgical hypoparathyroidism
  • Radical neck dissection
  • Massive administration of citrated blood
  • Pancreatitis
  • Kidney injury
  • Prolonged bed rest/bedridden patients
• Clinical Manifestations:
  • Tetany: general muscle hypertonia with tremor and spasmodic or uncoordinated contractions occurring with or without efforts to make voluntary movement
  • Latent Tetany: numbness, tingling, and cramps in the extremities, stiffness of hands and feet
  • Overt Tetany: Bronchospasm, laryngospasm, (+) Trousseau’s sign: carpopedal spasm resulting from occlusion of the blood flow to the arm for 3 minutes, (+) Chvostek’s sign: sharp tapping over the facial nerve causes spasm or twitching of mouth, nose, eye, seizures, dysrhythmias - torsades de pointes, photophobia
  • Hypotension
  • ECG Changes: prolonged QT interval and lengthened ST segment
  • Labs: hypomagnesemia
• Medical Management
  • Calcium salts IV
    • Calcium gluconate (4.5 mEq)
    • Calcium chloride (13.5 mEq)
  • Vitamin D - increases calcium absorption from the GI tract
  • Calcium supplements (to be taken with meals)
  • High calcium diet
    • Milk products
    • Green, leafy vegetables
    • Canned salmon
    • Canned sardines
    • Fresh oysters
• Nursing Management:
  • Administer calcium salts via slow IV/slow IV infusion
  • Assess IV site for evidence of infiltration
  • Do not use PNSS as it increases renal calcium loss; use D5W instead to dilute solution
  • Do not use concurrently with solutions containing phosphates or bicarbonate
  • Encourage intake of calcium-rich foods
  • Advise to quit smoking and consume alcohol and caffeine in moderation
  • Advise to avoid overuse of laxatives and antacids that contain phosphorus
  • Monitor and maintain airway patency
  • Institute seizure precautions
    • Reduce environmental stimulation
    • Identify and modify triggers
    • Padded side rails
    • Bed in lowest position
    • Oxygen and suction readily available

Hypercalcemia

• Serum Calcium Level: > 10.5 mg/dL
• Causes
  • Malignancies
  • Hyperparathyroidism
  • Thiazide diuretics
  • Vitamin A and D toxicity
  • Chronic lithium use
  • Theophylline toxicity
• Clinical Manifestations: “BACK ME UP”
  • B - Bone pain
  • A - Arrhythmias (heart blocks, shortened QT interval and ST segment)
  • C - Cardiac arrest (MOST DANGEROUS), constipation
  • K - Kidney stones
  • M - Muscle weakness
  • E - Excessive urination
  • U - Uhaw (thirst)
  • P - Pathologic fractures
• Medical Management
  • 0.9% NaCl solution - temporarily dilutes serum calcium and increases urinary calcium excretion
  • Furosemide (Lasix)
    • Used in conjunction with PNSS
    • Promotes diuresis and enhances calcium excretion
  • Calcitonin IM
    • Lowers calcium level by increasing calcium and phosphorus deposition into bones
    • Useful for patients with heart disease or kidney injury
  • Corticosteroids - Decrease bone turn over and tubular reabsorption for patients with sarcoidosis, myelomas, lymphomas, and leukemia
• Nursing Management
  • Monitor I&O
  • Assess for complications like dehydration, renal calculi, and cardiac dysrhythmias
  • Monitor vital signs
  • Encourage patient to increase fluid intake, avoid foods high in calcium
  • Institute safety precautions
  • Encourage ambulation and exercise
  • Educate about dietary restrictions and the importance of compliance with prescribed medications
  • Encourage follow-up care with their physician, including monitoring of serum calcium levels.

This quiz explores fluid overload (hypervolemia), including its causes, clinical manifestations, and management strategies. Participants will assess their understanding of the medical and nursing management approaches necessary for treating this condition. Perfect for nursing students and healthcare professionals.