NCM112-Mods-4A-4L.pdf

UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory,...

UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture [TRANS] UNIT XX: OVERVIEW OF FLUID AND ELECTROLYTES IMBALANCES Additional Information Module 4A Body fluid normally moves between the two major Overview of Fluid and Electrolytes Imbalances compartments or spaces in an effort to maintain equilibrium between the spaces. Outline Loss of fluid from the body can disrupt this equilibrium. 1. Discuss the functions of fluid (water) and its body Sometimes fluid is not lost from the body but is unavailable compartment. 2. Enumerate and identify the different electrolytes and its for use by either the ICF or ECF. location to the body compartment. Loss of ECF into a space that does not contribute to 3. Differentiate between osmosis, diffusion, filtration, and equilibrium between the ICF and the ECF is referred to as active transport by giving examples. a third-space fluid shift, or third spacing (McPhee et al., 4. Identify the different laboratory test used in evaluating 2012). fluid status. Early evidence of a third-space fluid shift is a decrease in 5. Describe the role of the kidneys, lungs, and endocrine urine output despite adequate fluid intake. glands in regulating the body’s fluid composition and Urine output decreases because fluid shifts out of the volume. intravascular space; the kidneys then receive less blood and attempt to compensate by decreasing urine output. Overview of Fluid and Electrolytes Imbalances Other signs and symptoms of third spacing that indicate an intravascular fluid volume deficit (FVD) include increased Water heart rate, decreased blood pressure, decreased central Maintains blood volume (plasma). venous pressure, edema, increased body weight, and Transport’s gases, nutrients, and other substances to the imbalances in fluid intake and output (I&O). cells. Third-space shifts occur in patients who have Promotes cellular chemical function. hypocalcemia, decreased iron intake, severe liver diseases, o Ions: most are essential electrolytes. alcoholism, hypothyroidism, malabsorption, immobility, ▪ Cations: Positive electrical charge burns, and cancer (Guyton & Hall, 2011). ▪ Anions: Negative electrical charge Maintains normal body temperature. Body Fluid Compartments Eliminates waste products from the cells. Two (2) Body Compartments 1. Intracellular Fluid Compartment (65%) Fluid in the cells. About two-thirds of total body water or approximately 25 liters. Found in the skeletal muscle mass. 2. Extracellular Fluid Compartment Fluid outside the cells. Approximately 1/3. Three (3) Division A. Interstitial Fluid Space Contains the fluid that surrounds the cell. 11 to 12 liters in an adult. Lymph is an interstitial fluid. B. Intravascular Fluid Space Fluid within the blood vessels contains plasma, effective CTTO: https://slideplayer.com circulating volume. 3 liters of the average 6 liters of blood volume in adults is made up of plasma. The remaining 3 liters is made up of erythrocytes, leukocytes, and thrombocytes. C. Trans Cellular Fluid Smallest division of the ECF compartment. Contains approximately 1 liter. E.g., cerebrospinal, pericardial, synovial, intraocular, and pleural fluids, sweat, and digestive secretions. Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 1  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture Factors Influencing Body Water Distribution Electrolytes in the Human Body Cations Anions 1. Age Sodium Chloride Younger people have higher percentage of body fluid Potassium Bicarbonate (young adults, fetus, neonates/newborns). Calcium Phosphate Magnesium Sulfate 2. Gender Hydrogen ion Proteins Men has more body fluids than women. Organic acids 3. Ratio of Lean Mass to Body Fat Note: Obese have less fluid than those who are thin, because fat Sodium: the major cation outside the cell. cells contain little water. Chloride: the major anion outside the cell. Skeleton has low water content. Potassium: the major cation inside the cell. Muscle, skin, and blood contain the highest amounts of Bicarbonate and Phosphate: the major anion inside water (Porth, 2011). the cell. Approximate Major Electrolyte Content in Body Fluids Electrolytes mEq/L Extracellular Fluid (Plasma) Cations Sodium (Na+) 142 Potassium (K+) 5 Calcium (Ca++) 5 Magnesium (Mg++) 2 Total cations 154 Anions Chloride (Cl-) 103 Bicarbonate (HCO3-) 26 Phosphate (HPO4-) 2 Sulfate (SO4-) 1 Organic acids 5 Proteinate 17 Total anions 154 Intracellular Fluid Cations Potassium (K+) 150 CTTO: https://twitter.com/ Magnesium (Mg++) 40 Sodium (Na+) 10 Total cations 200 Anions Phosphates and sulfates 150 Bicarbonate (HCO3-) 10 Proteinate 40 Total anions 200 CTTO: https://www.researchgate.net Solutes Substances dissolved in a solution. Classified as electrolytes or non-electrolytes. 1. Non-Electrolytes CTTO: https://www.interactivephysiology.com/ Glucose, CHON’s, lipids, O2, CO2, and organic acids. Sodium ions, which are positively charged in ECF, affects 2. Electrolytes the overall concentration of the ECF and important in (Ions) in body fluids are active chemicals. regulating the volume of body fluid. Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 2  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture Retention of sodium is associated with fluid retention, and Osmotic pressure exerted by proteins (e.g., albumin). excessive loss of sodium is usually associated with decreased volume of body fluid. C. Osmotic Diuresis Major electrolytes in the ICF are potassium and phosphate. The increase in urine output caused by the excretion of ECF has a low concentration of potassium and can tolerate substances such as glucose, mannitol, or contrast agents only small changes in potassium concentrations. in the urine. Release of large stores of intracellular potassium, typically Sodium-Potassium Pump caused by trauma to the cells and tissues, can be extremely dangerous. Sodium and potassium move in and out of cell because of active transport due to requiring ATP. The body expends a great deal of energy maintaining the Passive transport examples are: high extracellular concentration of sodium and the high o Diffusion: movement of solutes from area of higher intracellular concentration of potassium. It does so by means of cell membrane pumps that exchange sodium and concentration to lower concentration. potassium ions. o Ultrafiltration: requires a pressure from solutes to cross the cell membrane. Normal movement of fluids through the capillary wall into o Osmosis: diffusion of water (movement of solutes from the tissues depends on hydrostatic pressure (the pressure area of lower concentration to higher concentration). exerted by the fluid on the walls of the blood vessel) at both Facilitated transport examples are: the arterial and the venous ends of the vessel and the osmotic pressure exerted by the protein of plasma. The o Glucose carried by insulin. direction of fluid movement depends on the differences in these two opposing forces (hydrostatic vs. osmotic Note: Solute movement from one body compartment to another pressure). occurs through active or passive transport. Regulation of Body Fluid Compartments Sodium-Potassium Pump Osmosis Diffusion of water (movement of solutes from area of lower concentration to higher concentration). Osmolality Concentration of body fluids that affects the movement of fluid by osmosis. Reflects hydration status. Measured by serum and urine. o Normal serum (plasma and blood): 270 to 300 mOsm/kg or L o Normal urine: 500 to 800 or 400 to 800 mOsm/L or kg Note: The magnitude of this force depends on the number of particles dissolved in the solutions, not on their weights. The number of dissolved particles contained in a unit of fluid determines the osmolality of a solution, which influences the movement of fluid between the fluid compartments. CTTO: https://www.toppr.com Tonicity Proteins Ability of all solutes to cause an osmotic driving force that Solutes confined to the plasma that create colloid osmotic promotes water movement from one compartment to pressure in the ECF, affecting fluid and solute movement another. between the ECF and ICF. The control of tonicity determines the normal state of cellular hydration and cell size. Albumin Sodium, mannitol, glucose, and sorbitol are effective Specific protein that maintains oncotic pressure (colloid osmoles (capable of affecting water movement). osmotic pressure) that maintains fluid on their proper compartments. Three (3) Other Terms That are Associated with Decreased albumin → there is shifting in the fluid (e.g., Osmosis Ascites by low albumin level) o Water-pushing pressure: hydrostatic pressure A. Osmotic Pressure o Water-pulling pressure: oncotic pressure Amount of hydrostatic pressure needed to stop the flow of Solutions water by osmosis. Liquids (solvents) containing dissolved substances. Primarily determined by the concentration of solutes. They are classified according to their concentration or B. Oncotic Pressure tonicity. Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 3  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture Three (3) Types of Solution Movement occurs until near equal concentration found. Passive process A. Isotonic Osmosis Solution that has the same solute concentration as another solution (such as body fluids). B. Hypotonic Solutions that have a lower solute concentration than another solution. C. Hypertonic Solutions that have a higher solute concentration than another solution. Types of Solutions and their Effects to RBC’S CTTO: https://quizlet.com 2. Diffusion Movement of solutes from an area of higher concentration to an area of lower concentration in a solution and/or across a permeable membrane (permeable for that solute). Movement occurs until near equal state. Passive process. Intravenous Fluid Comparison Solution Constituents Tonicity Sodium: Normal Saline 154 mEq/l Isotonic (NS) Chloride: 154 mEq/l 1/2 Normal Sodium: 77 mEq/l Hypotonic Saline (1/2 NS) Chloride: 77 mEq/l Isotonic (become Dextrose 5% Dextrose: 278 hypotonic as (D5W) mmol/l dextrose is metabolized) Sodium: 77 mEq/l Dextrose 5% in Chloride: Hypertonic ½ NS 77 mEq/l Dextrose: 278 mmol/l Sodium: 130 mEq/l Chloride: 109 mEq/l Lactated Lactate: Isotonic Ringers 28 mEq/l Potassium: 4 mEq/l Osmosis vs. Diffusion Calcium: 3 mEq/L Osmosis Diffusion Low to high High to low Regulation of Fluids in Compartments Water potential Movement of particles Note: Both can occur at the same time. 1. Osmosis Movement of water through a selectively permeable 3. Active Transport membrane from an area of low solute concentration to a higher concentration until equilibrium occurs. Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 4  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture Allows molecules to move against concentration and Osmotic Pressure and Hydrostatic Pressure osmotic pressure to areas of higher concentration. Active process → energy is expended. A. Osmotic Pressure The sodium concentration is greater in the ECF than in the Power of the solution to draw water across the semi- ICF; because of this, sodium tends to enter the cell by permeable membrane. diffusion. This tendency is offset by the sodium– potassium pump that is maintained by the cell membrane and actively Colloid Osmotic Pressure moves sodium from the cell into the ECF. Pressure that pulls water from the interstitial space into the Conversely, the high intracellular potassium concentration vascular compartment, to maintain vascular volume. is maintained by pumping potassium into the cell. By definition, active transport implies that energy must be B. Hydrostatic Pressure expended for the movement to occur against a Pressure exerted by fluid within a closed system on the concentration gradient. walls of the container in which it is contained. Sodium-Potassium Pump Capillary Microcirculation CTTO: https://slideplayer.com CTTO: https://training.seer.cancer.gov Passive and Active Transport Tissue Fluid Formation CTTO: https://slidetodoc.com Systemic Routes of Gains and Losses Water and electrolytes are gained in various ways. Healthy CTTO: https://sites.google.com people gain fluids by drinking and eating, and their daily average I&O of water are approximately equal. 4. Filtration The process whereby fluid and solutes move together Sources of Body Water Gains and Losses in the across the membrane from one compartment to another. Adult Type of passive transport that results from hydrostatic pressure. 1. Kidneys Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 5  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture The usual daily urine volume in the adult is 1 to 2 liters (Porth, 2011). A general rule is that the output is approximately 1 mL of urine per kilogram of body weight per hour (1 mL/kg/h) in all age groups. Table 7-3: Average Daily Intake and Output of an Adult Category Amount Intake Oral liquids 1,300 ml Water in food 1,000 ml Water produced by 300 ml metabolism Total gain 2,600 ml Output Urine 1,500 ml Stool 100 ml Insensible Lungs 400 ml Skin 600 ml Total loss 2,600 ml 2. Skin Sensible perspiration refers to visible water and electrolyte loss through the skin (sweating). The chief solutes in sweat are sodium, chloride, and potassium. Actual sweat losses can vary from 0 to 1,000 mL or more every hour, depending on factors such as the environmental temperature. Continuous water loss by evaporation (approximately 500 mL/day) occurs through the skin as insensible perspiration, a nonvisible form of water loss (Porth, 2011). Fever greatly increases insensible water loss through the lungs and the skin, as does the loss of the natural skin barrier (e.g., through major burns). 3. Lungs The lungs normally eliminate water vapor (insensible loss) at a rate of approximately 300 mL every day (Porth, 2011). The loss is much greater with increased respiratory rate or depth, or in a dry climate. 4. Gastrointestinal Tract The usual loss through the gastrointestinal (GI) tract is 100 to 200 mL daily, even though approximately 8 L of fluid circulates through the GI system every 24 hours. Because the bulk of fluid is normally reabsorbed in the small intestine, diarrhea and fistulas cause large losses. Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 6  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture [TRANS] UNIT XX: FLUID VOLUME DEFICIT Apathetic, confused or very ill patients Module 4B Infants Fluid Volume Deficit Patient with cerebral injury Patients with increased temperature Outline Patients with diabetes insipidus 1. Describe how fluid volume deficit happens in the human body. Burn patients 2. Enumerate the causes and risk factors of fluid volume Types of Fluid Volume Deficit deficit. 3. Formulate nursing diagnosis based on the clinical manifestation and assessed data. 1. Isotonic Fluid Volume Deficit 4. Demonstrate the different medical and nursing Most common type. management in the care of client with fluid volume deficit. Equal loss of both electrolytes and fluid. Normal serum osmolality. Fluid Volume Deficit / Hypovolemia An extra cellular fluid volume loss A decrease in: o Intravascular, interstitial, and/or intracellular Causes o Fluid in the body Hemorrhage It occurs when loss of ECF volume exceeds the intake of GI losses fluid. Fever, environmental heat and diaphoresis It occurs when water and electrolytes are lost in the same Burns proportion as they exist in normal body fluids, thus the ratio Diuretics of serum electrolytes to water remains the same. Third space shift It should not be confused with dehydration, which refers to o Shift of fluid from the vascular space into an area where loss of water alone, with increased serum sodium levels. it is not available to support normal physiologic FVD may occur alone or in combination with other processes imbalances. o Common location: abdomen, pleural spaces, and pericardial space. Causes of Fluid Volume Deficit o Causes: injury or inflammation, burns, cancer, massive Inadequate fluid intake trauma, malnutrition or liver dysfunction, and low Output is greater than intake oncotic pressure. Abnormal fluid losses such as those resulting from: o Vomiting 2. Hypertonic Fluid Volume Deficit o Diarrhea Water deficit is greater than electrolyte deficit. o GI suctioning Elevated serum osmolality. o Sweating Cells shrink o Lack of access to fluids Fluid loss is both extracellular and intracellular o Third-space fluid shifts, or the movement of fluid from the vascular system to other body spaces (e.g., with Causes edema formation in burns, ascites with liver Inadequate fluid intake dysfunction) Severe or prolonged isotonic fluid losses o Additional causes include diabetes insipidus (a Watery diarrhea decreased ability to concentrate urine flowing to a Diabetes insipidus defect in the kidney tubules that interferes with water Increased solute intake without a proportional intake of reabsorption), adrenal insufficiency, osmotic diuresis, water hemorrhage, and coma. Conditions leading to hypertonic FVD In Hypovolemia Highly concentrated enteral or parenteral feedings Body loses fluid Hyperglycemia and/or diabetic ketoacidosis Increased blood concentration Increased sodium ingestion Increased serum sodium Excess osmotic diuretic use Water molecules shift out of cells Insufficient water intake/retention to restore Note: Cells shrink as more fluids shifts out of them A person can go several weeks to months without food, but Patient develops mental status changes only two to three days without water. Risk Factors Manifestations Age, gender, and body fat Decreased turgor and elasticity Acute illness Concentrated urine and low urine Thirst Chronic illness Dry mucous membranes Environmental factors Dry skin with volume Diet and lifestyle Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 1  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture Sunken eyeballs; sunken or depressed fontanels in infants 2. Urine Specific Gravity Flat neck veins and poor peripheral vein filling Measures the ratio of the density of urine as compared to Hypotension the density of an equal volume of water. Mental status → the first sign noticed in elderly, infants and An indicator of the kidney's ability to reabsorb water and young children chemicals from the glomerular filtrate. Acute weight loss Decreased CVP 3. Evaluates Hydration Status and Detects Problems with Antidiuretic Hormone Levels Assessing Skin Turgor in Elderly Clients Normal range:1.010 to 1.030 Forehead Fluid volume deficit – high Sternum Fluid volume excess – low Inner thigh Top of the hip bone 4. Blood Urea Nitrogen Measures the nitrogen fraction of urea, the chief end Assessing Skin Turgor in Infants product of protein metabolism. Abdomen Formed by the liver from ammonia and excreted by the Thigh kidney. Normal: 10 to 20 mg/dL Note: Dry tongue with longitudinal furrows is a reliable sign in all Laboratory Findings in FVD age group. Normal Values Remember 1. With normal or high hematocrit: Systolic BP falls more than 15 mm Hg. o Women: 35% to 45% Diastolic BP falls more than 10 mm Hg. o Men: 40% to 50% Pulse increases of 30 beats/min or more. o Infants: 28% to 42% o Children: 35% to 45% Note: 2. Normal or high BUN Weight is considered the most accurate indicator of fluid 3. High urine specific gravity status than I&O except in third spacing. o >1.030 or less in DI Degree of Fluid Volume Deficit In Hypertonic Dehydration Degree Description 1. Serum osmolality elevated: >300 mOsm/kg 2% of body weight loss 2. Serum sodium elevated (hypernatremia): >150 mEq/L May only see thirst 3. Serum glucose elevated (if that is the cause of the Mild 1 to 2 L fluid loss in adult dehydration): > 120 mg/dL 2.2 lbs. = 1 kg = 1L 5% of body weight loss Priority Nursing Diagnoses Signs and symptoms Deficient fluid volume Moderate / Marked appear Risk for hypovolemic shock 3 to 5 L fluid loss in adult Risk for injury 8% body weight loss Risk for impaired skin integrity 5 to 10 L fluid loss in adult Ineffective tissue perfusion, renal Same symptoms as marked dehydration plus Medical Management Severe Systolic BP = < 60 mmHg Oral replacement therapies → the oral route is preferred, Restlessness, irritability, provided the patient can drink. disorientation, and delirium Parenteral replacement therapies → if fluid losses are acute More than 15% body or severe. weight loss o Isotonic electrolyte solutions (e.g., lactated Ringer’s Fatal More than 10 L fluid loss solution, 0.9% sodium chloride) are frequently the first- in adult line choice to treat the hypotensive patient with FVD Anuria; coma because they expand plasma volume (Crawford & Harris, 2011c) Laboratory Test o Normotensive patient, a hypotonic electrolyte solution (e.g., 0.45% sodium chloride) is often used to provide 1. Urine Osmolality both electrolytes and water for renal excretion of Measures the concentration of numbers of particles of metabolic wastes. solute in the urine. Medications: Reflects the kidney's ability to concentrate urine. o Antiemetics o Antidiarrheal 500 to 800 mOsm/kg o Antipyretics Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 2  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture o Vasopressin (Pitressin) Nursing Management Restore oral fluid intake. o Increase oral fluid of choice o Give antiemetics o Clear liquids to solid foods Restore fluids by intravenous routes. Reduce the risk of deficient fluid volume. o Maintain level of fluid intake at 1500 ml for 24 hours o Give water boluses with hypertonic tube-feedings o Avoid caffeine o Recommend early progression to a soft, easily digestible, regular diet Monitor monitors and measures fluid I&O at least every 8 hours, and sometimes hourly. Vital signs are closely monitored. The nurse observes for weak, rapid pulse and orthostatic hypotension (i.e., a decrease in systolic pressure exceeding 20 mm Hg when the patient moves from a lying to a sitting position) (Weber & Kelley, 2010). A decrease in body temperature often accompanies FVD, unless there is a concurrent infection. Skin and tongue turgor are monitored on a regular basis. Urine concentration is monitored by measuring the urine specific gravity. Monitor mental function Complications of FVD Shock Renal failure Fever Coma Jopar Jose C. Ramos | Bachelor of Science in Nursing 3-A 3  UA-CONP: C-NCM112 aidè à vivrè Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory, #HelpLive Immunologic Response, and Cellular Aberration (Acute and Chronic) Lecture [TRANS] UNIT XX: FLUID VOLUME EXCESS Prevention Module 4C Do not give excessive tap water enemas. Fluid Volume Excess Do not force fluids on patient with DI. Monitor I and O and daily weight. Outline Do not replace losses of both sodium and water with plain 1. Discuss how fluid volume excess occurs in the body. 2. Identify possible causes of fluid volume excess. water alone. 3. List down the different clinical manifestations that can be Do not excessively irrigate an NGT with plain water. Instead assessed for client with fluid volume excess. use normal saline for irrigation. 4. Execute the medical and general nursing management in Do not increase the rate of drip of an IV infusion simply the care of client with fluid volume excess. because the IV is behind schedule. 5. Utilize the nursing process in the provision of safe and quality nursing care for patient with fluid volume excess. Edema Accumulation of fluid within the interstitial spaces. Fluid Imbalances Forces Favoring Fluid Movement From the Fluid Volume Excess or Hypervolemia Capillaries into the Tissues Increased fluid in either the interstitial or intravascular Increased hydrostatic pressure spaces (e.g., peripheral edema and pulmonary edema). Lowered plasma oncotic pressure Refers to an isotonic expansion of the ECF caused by the Increased capillary permeability abnormal retention of water and sodium in approximately Lymphatic obstruction the same proportions in which they normally exist in the ECF. Anasarca Generalized edema. Cause More uniform distribution of fluid in the interstitial space. Excess water and sodium intake Impairment of the mechanisms that maintain homeostasis Dependent Edema Fluid accumulates in gravity-dependent areas of the body, Types of Fluid Volume Excess might signal more generalized edema. Appears in the feet and legs when standing and in the 1. Isotonic Fluid Volume Excess sacral area and buttocks when lying. Both water and sodium are retained in proportional amounts. Other Manifestations of Edema Weight gain Causes Swelling and puffiness Renal failure Tight-fitting clothes and shoes Heart failure Limited movement of the affected area Excess intake Pulmonary edema Isotonic IV solutions infused too rapidly High corticosteroid and aldosterone levels Clinical Manifestations of FVE Increase in total body water 2. Hypotonic Fluid Volume Excess Signs and symptoms of circulatory overload Also called water intoxication. Peripheral edema More fluid is gained than solute (primarily sodium). Third spacing Leads to cell swelling Polyuria Tense fontanel Causes Possible altered mental status and anxiety Repeated plain water enemas or repeated plain water NG tube or bladder irrigations. Clinical Manifestations of Peripheral Edema Overuse of hypotonic IV fluids or infusing hypotonic fluids Pitting edema in extremities too rapidly. Tight, smooth shiny skin over edematous area Overzealous plain water intake to replace isotonic fluid and Puffy eyelids electrolyte losses. Weight gain In young children and infants, a common cause is ingestion of inappropriately prepared formula and/or excess water. Diagnostic and Laboratory Findings SIADH Hct and BUN (decreased) Serum osmolality (decreased) Laboratory Findings in SIADH o