What are the signs of volume deficit?

Full Transcript

Hi, I'm Cathy, with Level Up RN. In this video, I am going to talk about fluid-volume deficit and fluid-volume access. Very important topics. You can see there's a lot of bold red text on these cards. So if you have our medical-surgical nursing flashcards, definitely pay attention to that bold red text and review those items. So at the end of the video, I'm going to provide you guys a little quiz to test your knowledge of some of the key facts I'll be covering in this video. So definitely stay tuned for that. And if you have our cards, be sure to pull those out so you can follow along with me.

With fluid-volume deficit, our fluid output exceeds our fluid intake, which causes hypovolemia.

Risk factors associated with fluid-volume deficit include GI losses such as excess vomiting, diuretics, hemorrhaging, diabetes insipidus, as well as hyperventilation. Those are just some of the risk factors.

In terms of signs and symptoms, when we have a lack of fluid volume, that's going to cause our blood pressure to drop. So we're going to have hypotension. And then your body will try to compensate for this hypotension by increasing your respiration rate and your heart rate. So you're going to have tachypnea and tachycardia. We're also going to see weak, thready pulses when a patient has fluid-volume deficit. They may feel weak and thirsty. In addition, we will see prolonged capillary refill time. We'll see oliguria. So that means not a lot of urine, which makes sense. If the patient is dehydrated or lacking in fluid volume, they're not going to be peeing a lot. And then, we're also going to see flattened jugular veins.

So in terms of labs, we're going to have concentrated blood and concentrated urine. So we're going to see an increase in hematocrit as well as serum osmolarity and BUN. And then, our urine is going to be concentrated as well. So we're going to see an increase in urine specific gravity as well as urine as uring osmolarity.

In terms of treatment, we're going to provide the patient with IV fluid replacement.

And then for nursing care, we're going to closely monitor the patient's I's and O's because if their urine output drops below 30 milliliters an hour, then that may be indicative of hypovolemic shock. So we're definitely going to want to notify the provider if that urine output falls below 30. And then, we're also going to want to implement fall precautions because the patient's going to be weak and more likely to fall.

With fluid-volume excess, we have hypervolemia. So we have excessive intake of fluid or inadequate excretion of fluid.

Risk factors include kidney dysfunction. So the kidneys are supposed to get rid of excess fluid and electrolytes. So if the kidneys aren't working properly, then that fluid can back up into the body. Heart failure is another key risk factor for fluid-volume excess because if the heart's not beating effectively, then fluid can back up. Other risk factors include corticosteroids as well as cirrhosis.

In terms of signs and symptoms, signs and symptoms of fluid-volume excess can include weight gain, edema, hypertension, bounding pulses, as well as jugular vein distension. It can also cause tachycardia because the heart is being overwhelmed with all this excess fluid. So it will try to beat faster to compensate. The fluid can also back up into the lungs, and that can cause dyspnea as well as crackles and tachypnea.

So in terms of labs, when we were talking about fluid-volume deficit, everything was concentrated. The blood and the urine were both concentrated. Here, with fluid-volume excess, everything is diluted. So we're going to have a decrease in hemoglobin and hematocrit in the blood, and we're going to have a decrease in serum osmolarity. The urine is also going to be diluted. So we're going to have a decrease in urine specific gravity.

In terms of treatment, the go-to treatment for this is diuretics, and I have a whole video on diuretics in my pharmacology playlist. So you can check that out.

In terms of nursing care, we're going to want to weigh our patient on a daily basis. So not once a week, not every other day, every single day. And if the patient has a weight gain of one to two pounds within a 24-hour period or a weight gain of three pounds or more within a week, then we want to notify the provider. We also want to sit the patient up, and we may need to provide oxygen as well to make it easier to breathe. We're going to want to take great care for the patient's skin because their skin will be very fragile if they have a lot of excess fluid. It can be almost like tissue paper if the edema is really bad.

We also are likely going to be restricting the patient fluid and sodium intake per orders. And that's going to be really hard on the patient, and sometimes they'll try to hit up anybody who walks in the room to get more fluids. So as the bedside nurse, definitely write it on the whiteboard if the patient is on fluid restrictions, and definitely share that information with the care team as well.

As a wound care nurse, sometimes I'm taking care of a patient and as I'm leaving, I'm like, "Do you need anything before I go?" And they're like, "Can you get me some water?" And then I'll look at the whiteboard and I'll say fluid restriction, and I'll be like, "You know what? I'm going to have to check with the nurse," and they're like, "Oh. Almost got it."

Anyway, we also want to monitor for complications, which include pulmonary edema, because of that backup of fluid on the lungs, as well as heart failure. So heart failure can cause fluid-volume excess. It can also be a complication of fluid-volume excess.

All right. Time for a quiz. Are you guys ready? I have three questions for you. Question number one. When caring for a patient with fluid-volume excess, what amount of weight gain should you report to the provider? The answer is one to two pounds in 24 hours, or three pounds in a week. Question number two. An increase in serum osmolarity and urine specific gravity is expected with fluid-volume excess. True or false? The answer is false. So we would expect this increase with fluid-volume deficit. Question number three. When caring for a patient with a fluid-volume deficit, a urine output less than 30 milliliters per hour may indicate hypovolemic shock. True or false? The answer is true. Okay. I hope that quiz was helpful, and I hope this video has been helpful as well. If so, be sure to like the video and leave me a comment. Take care and good luck with studying.

• Sometimes serum electrolytes, blood urea nitrogen (BUN), and creatinine

• Rarely plasma osmolality and urine chemistries

Volume depletion is suspected in patients at risk, most often in patients with a history of inadequate fluid intake (especially in comatose or disoriented patients), increased fluid losses, diuretic therapy, and renal or adrenal disorders.

Diagnosis is usually clinical. If accurate patient weights immediately before and after fluid loss are known, the difference is an accurate estimate of volume loss; for example, pre- and post-workout weights are sometimes used to monitor dehydration in athletes.

Some devices can help assess volume status but are not in widespread use. Point-of-care ultrasonography evaluating inferior vena cava distension is sometimes used to assess volume status when the severity of volume loss is unclear. Also, ultrasonography of the lungs can show findings of pulmonary edema and thus fluid overload. Central venous pressure and pulmonary artery occlusion pressure are decreased in volume depletion, but measurement with an invasive device such as a central venous catheter or pulmonary artery catheter is rarely required, although it is occasionally necessary for patients for whom even small amounts of added volume may be detrimental, such as those with unstable heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid... read more

Chronic Kidney Disease Chronic kidney disease (CKD) is long-standing, progressive deterioration of renal function. Symptoms develop slowly and in advanced stages include anorexia, nausea, vomiting, stomatitis, dysgeusia... read more

The following concepts are helpful when interpreting urine electrolyte and osmolality values:

• During volume depletion, normally functioning kidneys conserve sodium. Thus, the urine sodium concentration is usually low,< 15 mEq/L (< 15 mmol/L); the fractional excretion of sodium (urine sodium/serum sodium divided by urine creatinine/serum creatinine) is usually < 1%; also, urine osmolality is often high,> 450 mOsm/kg (> 450 mmol/kg).

• Misleadingly high urinary sodium (generally > 20 mEq/L [> 20 mmol/L]) or low urine osmolality can also occur due to renal sodium losses resulting from renal disease, diuretics, or adrenal insufficiency.

Volume depletion frequently increases the BUN and serum creatinine concentrations; the ratio of BUN to creatinine is often > 20:1. Values such as hematocrit often increase in volume depletion but are difficult to interpret unless baseline values are known.