Now let's look into fluid volume excess. So fluid volume excess meaning there's
too much fluid in the patient's intravascular system. And causes of that
can be rapid IV fluid administration. So for example, if this is an elderly
patient who has a weak heart and their heart is not really able to pump very
efficiently, and they might have a certain degree of congestive heart
failure. Now if we give IV fluids to them too fast, the heart
is not able to to pump that very efficiently and also maybe if the
kidneys are impaired the patient's not going to even be able to filter it, so
rapid fluid administration can lead to fluid volume access as well as
congestive heart failure as I just explained. If the patient's heart is
weakened and that heart muscle can't really pump the fluids into the body
very, very efficiently, then the fluid tends to back up. In congestive heart
failure, whether it's right or left sided, into the lungs or into the body. And then
the patient will have signs of fluid volume excess. Also renal failure, so our
patients whose kidneys are not working properly for whatever reason, whether
it's acute or chronic, the kidneys have taken some sort of an insult where they
are not able to filter out the fluid as they would usually, so then the kidneys
are not filtering, that's really our only way of exiting or getting rid of excess
fluids, so if the kidneys are not functioning, we're going to be retaining
more fluids, hence we're going to have fluid volume
excess. Also patients with cirrhosis, so the liver is a major organ
who does not really contribute that much to fluid and electrolyte balance but if the
liver is not functioning, the patients will usually get what's called ascites,
which means that the fluid accumulates in the interstitial space. So that can be
the lower extremities as well as the abdominal cavity and you can look into
cirrhosis a little bit more clearly here. So the patients fluid volume excess will
not necessarily be in the intravascular space but it will be in that
interstitial space, again lower extremity or in the abdominal area, and there will
be fluid volume excess in those areas. Also excessive water intake can lead to
fluid volume excess. So typically we think of water being a good thing, we
want everybody to be hydrated, drink plenty of fluids, but there is such a
thing is too much of a good thing. So if you drink too much water, let's say if you
drink five gallons of water a day, your body is going to be
completely diluted, and there's going to be some consequences,
having fluid volume excess. So let's look at the lab values here. Now if we have
fluid volume excess, too much fluid in the intravascular, or in cirrhosis in the
interstitial, space, everything will be more diluted because all the particles
that we have now, that we can measure in the serum will be floating around in
more fluid than they usually are, so everything will be everything will be
more diluted, meaning our BUN value will be low, our sodium level will typically be low,
so will be the hematocrit, so the percentage of blood compared to the
plasma, and then urine specific gravity, again I wrote
parentheses here because typically when there's fluid volume excess the kidneys
will get rid of more fluid, hence the urine will be more dilute, but if there's
renal failure and the kidneys are not working, this is not going to apply
because the kidneys are not going to be able to filter and then the
urine specific gravity might be normal or it might actually be a little bit
high. But as it applies to serum osmolarity again that will be lower
because every particle that floats around in our intravascular system will
be more dilute - hemodilution right here. So everything, just note all the arrows
point down here, and know urine specific gravity in parenthesis. So patients
with fluid volume excess - we will definitely have to also monitor the
cardiovascular status, their vital signs, so if you think about it if a patient
has too much fluids in their system their blood pressure will usually be
elevated. Now depending on how the heart is doing or whatever other comorbidities
or conditions they have, the heart rate may be normal, high, low, it depends on a
variety of other factors. But then the patient with fluid volume excess will
definitely have jugular venous distention and if you want to refer back
to your text book, then you can see how this is measured but basically if there
is a lot of fluid in the intravascular system and the patient is sitting in bed
at 45 degrees, we can measure the angle of the jugular vein and depending on how
many centimeters it is distended, it would be a positive or negative
finding. And mostly in with fluid volume excess the jugular veins will be
distended. Now there will also be peripheral edema if the cause is either
congestive heart failure, renal failure, even cirrhosis, there's too much volume
in the blood system that eventually that blood will push out, it will seep
out from the intravascular space and just kind of sit there in the
interstitial space. And the manifestations are peripheral edema as
well as maybe ascites, like I explained earlier in the patient with cirrhosis.
Now we'll also have to keep a close eye again of the patient's lung sounds
because there is too much volume already in their system, if the heart is not
pumping efficiently, that left ventricle was really weak, that fluid will back up
into the lungs and a pretty typical lung sound in the
patient with CHF or an exacerbation of CHF will be crackles in the lungs. So
keep that in mind. Again, we want to make sure we watch the patient for safety
because they have this extra fluid, they might be swollen, they might be short of
breath, so they are a high fall risk again. We want to pay particular attention to
their skin because they'll have edema, they'll have ascites, they'll be very
swollen if there's a lot of fluid in the interstitial space it can actually
sometimes even seep out through the skin depending on how severe the edema is.
So skin care is going to be very important to prevent any further
complications. Now IV fluids as ordered so that all
depends on how significantly the edema is, how significant the fluid volume excess is,
it typically the patient will be saline locked, but maybe the excess, the fluid
volume excess is improving, we might give the patient IV fluids at just a very, very
slow rate. So something like 15 mls per hour. But be very careful
and check your orders here very carefully as the type of IV solution as well as
the rate because again if we have fluid volume excess we do not want to give the
patient any additional fluids. And then of course the patient, if there is
congestive heart failure, renal failure, or cirrhosis, when we'll need to
put some medications in that will help us get rid some of some of that fluid. Now
diuretics as we know work very very well in eliminating some of that excess
fluids via the kidneys that we need functioning kidneys. So in a patient with
renal failure, depending on the degree of renal failure, diuretics may or may not
work but diuretics work very well for patients with congestive heart failure.
And then also I wrote down your colloids or albumin as ordered.
So albumin is a plasma protein that exerts what's called oncotic pressure or
colloidal oncotic pressure in the system. So plasma proteins are very big
molecules that circulate in our bloodstream, and what they do is they
create a pulling force into the intravascular space, so that pulling
force really helps to contain all the molecules and the fluids in that
intravascular space. Typically patients with cirrhosis would have very low
albumin levels. The same can happen with patients with congestive heart failure
and then what happens that pulling force of the albumin into the
intravascular space is not really working properly,
hence the fluid seeps out into the interstitial space, as we talked about,
manifesting itself in edema or in the ascites in patients with cirrhosis but
then we can administer albumin via IV. So there's an artificial albumin that we
can give the patient, and that will create that pulling force in the
intravascular space by these proteins exert and so it'll help reduce
the amount of swelling and pull the interstitial space back, the
interstitial fluid back from the interstitial space into the
intravascular space. Now one very important thing I haven't written down
yet it is monitor Is and Os very, very carefully. That's probably the one
of the most important things to do here as well as daily weights.
For the same reason as we want to measure that very carefully in patients
with fluid volume deficit, we want to keep a close eye on their intake and
output and weigh them daily. Now if there is, was excessive water intake or any of
these other factors, really we might also put the patient on fluid restriction so
these are the patients that you'll see, will have a sign either at door or at
the bedside: "fluid restriction 1200 ml per day" and then you have to be very careful
and monitoring that. So, in summary, fluid volume deficit or fluid volume excess
pertains to either plasma or blood loss, depending on the condition for fluid
volume deficit you might lose plasma, fluid only, or blood. Everything in fluid
volume deficits and in terms of your labs will be more concentrated because
we've lost the fluid portion of it. And then we went over the nursing
interventions. Now for fluid volume excess it's quite the opposite. So
something in the body is not working quite right, mostly heart, kidneys, liver.
Therefore we're retaining a lot of fluid and everything will be more dilute in
our lab section. And then nursing interventions we talked about them as
well, the most important being monitoring the cardiovascular status as well as
Is and Os, daily weights, as well as for fluid volume deficit and excess.
So thank you very much for watching Nursing School Explained, I'll
be focusing on arterial blood gas analysis as well as the major electrolytes and
what it means if they are high or low in the system and certain nursing
interventions that go along with that in future videos. Please leave any comments
or topics you would like me to review in the future in the comment section below,
I'll be happy to look at those and I'll be happy to receive your feedback as
well. Thank you for watching Nursing School Explained.