The Body’s H20 Balancing Act

The Body’s H20 Balancing Act Judy Sabel BSN RN sabelja@alverno.edu Alverno College MSN 621

Outcomes • Describe signs and symptoms of fluid volume deficit and fluid volume overload • Identify risk factors, laboratory findings & nursing interventions for patients with fluid imbalance • Recognize the body’s mechanisms involved with fluid maintenance • Identify factors which can affect fluid balance

Tutorial directions Table of Contents • Return to the table of contents by clicking : • The bee signifies a question that will review tutorial content- click on this to answer *Make sure your pointer appears as shown • Navigate forward and backwards by clicking: shape

Table of Contents Dehydration Scenario Control of Fluid Balance Fluid Overload Scenario H20 Balance Puzzle Kidney Functions Stress Response, Inflammation & Genetics References Evaluating Edema Common Laboratory Values Nursing Interventions *Note all images are microsoft clipart unless otherwise noted

Table of Contents Dehydration Scenario Noah Watter a 81 yr. old recent widower was admitted today with dehydration. He was mowing his lawn when his neighbor found him lying on the ground with slurred speech. The outside temperature was 92⁰ with 80% humidity. He has a history of hypertrophic cardiomyopathy and hypertension. You will be his nurse today. iStock_000007337705XSmal

Table of Contents The following is your nursing assessment of Noah Watter: • Noah is alert and oriented x 3 • Temperature 99.8, HR 118, BP 88/60, RR 30 • SpO2- 92 on room air, breath sounds clear bilaterally • Skin diaphoretic, capillary refill <3 seconds • Peripheral pulses are thready and 1+ • Color is ashen, skin cool and clammy • Skin turgor poor, and tongue is dry • Urine output is decreased Microsoft clipart

Which of your assessment findings are abnormal and need to be reported to Noah’s physician? Table of Contents Capillary refill < 3 seconds SPO 92 on room air Alert and oriented x 3 HR 118, B/P 88/60 Incorrect Incorrect Incorrect Correct!!

Table of Contents Correct! HR and BP • Tachycardia is usually the earliest sign of decreased vascular volume. • Blood pressure is related to the amount of blood the heart pumps and the extent of vasoconstriction present. Fluid volume affects these elements, making blood pressure measurement key in assessing a patients fluid status. (Taylor, 2011) (Thompson, 2008)

Table of Contents Evaluating your patient’s pulse amplitude can give you clues to their hydration status. (Taylor, 2011) *When dehydrated your patient’s pulse may be thready.

Table of Contents The following assessment findings in Noah Watter are also significant for dehydration • Skin diaphoretic, temperature 99.8 • Peripheral pulses are thready and 1+ • Color is ashen, skin cool and clammy • Skin turgor (elasticity) poor and tongue is dry • Urine output is low

Table of Contents Noah’s physician ordered lab work with the following results • CBC: WBC 7,000/mm³, Hgb 17g/dl, Hct 57%, Platelets 350,000/mm³ • Chemistry: Na 162meq/L, K 5.0meq/L, CL 115meq/L, HCO3 15meq/L, BUN 23mg/dl, Creatinine 1.0mg/dl, Glucose 90mg/dl Click here to view common lab values Used with permission by the Washington Endocrine Clinic

Table of Contents Which lab values were abnormal for Noah? Correct!! HCT 57% and Na 162 K+ 5.0 WBC’s -7,000 Glucose 90 Incorrect Incorrect Incorrect

Table of Contents Correct! • Increased HCT – higher proportion of RBC compared to water in the blood. 57% means that a 100ml sample contains 57ml of packed RBC’s. • Increased electrolytes-elevated serum sodium level (above 145mEq/L). If more water is lost than NA+, serum sodium may be high. • High urine specific gravity result of renal vasoconstriction and increased secretion of ADH and aldosterone. • Increased BUN- reflects kidney’s decreased excretion of urea. • Low urine output & concentrated urine. (Eckman 2008 ) (Pagana 2006)

Table of Contents Noah Watter (an elderly male) was at risk for dehydration because…. The elderly have a lower proportion of water in their bodies The elderly have decrease in kidney function, thirst sensation, and functional sweat glands He was mowing his lawn in 90⁰ weather All of the above Incorrect Incorrect Incorrect Correct!!

Table of Contents Correct! Dehydration is a more serious problem for the elderly. • Lack significant fluid reserves • Lack ability to conserve fluid quickly • Watch for changes in mental status (Ackley 2006) • Prevalence of acute and chronic diseases makes them more susceptible to fluid imbalances • Skin may lack elasticity in the elderly skin turgor may be an unreliable sign • Check skin turgor of the elderly client on the forehead, sternum or inner thigh • Presence of longitudinal furrows (deep grooves on tongue) or dry mucous membranes is a good indication of dehydration Used with permission from Pethum Madusanka (Woodrow 2002)

Table of Contents Which nursing intervention is not necessary when monitoring Noah Watter’s condition? Incorrect Monitoring vital signs and cognitive function Providing frequent oral hygiene and mucous membrane assessment Placing a urinary catheter to assess intake and output Daily weights Incorrect Correct!! Incorrect

Table of Contents Correct!Although it is necessary to monitor intake and output it is not necessary to place a urinary catheter if your patient is continent. **It is especially important to monitor elderly clients for excess fluid volume during the treatment of dehydration: • Listen for adventitious lung sounds • Assess for edema • Monitor vital signs • Monitor daily weights (Ackley, 2006 )

Table of Contents The kidneys play a major role in fluid balance and maintaining homeostasis in the body. This amazing organ performs the following functions: • Removes wastes and water from the blood • Balances chemicals in the body • Release of hormones • Helps to control blood pressure • Helps to produce red blood cells • Activates vitamin D Click screen to view video!

Table of Contents The body holds fluid in two compartments. To maintain fluid balance the distribution between the two compartments must remain relatively constant. 1. Intracellular (ICF)- inside the cells. 2. Extracellular (ECF)- outside the cells Broken down further: • Intravascular fluid or plasma 25% • Interstitial fluid-surrounds the cells 75% • Infants have a greater percentage of body water stored inside interstitial spaces compared to adults . Many older people have less muscle but more fat and so have fewer water stores.

Table of Contents Fluids help maintain body temperature & help in transporting nutrients, gases, and wastes. To maintain this balance the amount of fluid gained throughout the day must equal the amount lost. (Gould, 2011 ) *Insensible losses can’t be measured or seen.

Table of Contents In order to maintain fluid balance the body relies on sodium and albumin to prevent too much fluid from leaving the capillaries. • Sodium-promotes water retention. Water follows sodium. *Maintains the osmotic pressure of extracellular fluid *Regulates renal retention and excretion of water *Maintains systemic blood pressure • Albumin-(magnet) for water. Water follows albumin. Large molecule which draws fluid to it -keeping fluid in the vascular space. This is called plasma colloid osmotic pressure. (Eckman, 2008)

Table of Contents Many mechanisms in the body work together to maintain fluid balance. The following make this amazing balancing act possible: • Thirst mechanism in the hypothalamus. • Kidneys- filter electrolytes, wastes & water into urine. • Hormonal systems- • Antidiuretic hormone (ADH)- Also known as vasopressin. Produced by the hypothalamus. • Renin- from the kidneys activates the renin-angiotensin-aldosterone (RAA) system. • Atrial natriuretic peptide ANP-produced and stored in the atria of the heart. • Brain natriuretic peptide BNP-secreted from the cardiac cells. (Eckman, 2008)

Table of Contents Antidiuretic hormone (ADH)- this water retainer is also called vasopressin. (Eckman, 2008) Holds water when fluid levels drop and releases it when fluid levels rise

Table of Contents Renin-angiotensin-aldosterone (RAA) system- through a complex series of steps, renin leads to the production of antiotensin II. . Angiotensin 1 is converted to angiotensin II Angiotensin II stimulates the adrenal glands to produce aldosterone Blood flow to the kidney decreases Renin converts angiotensinogen formed in the liver to antiotensin I Aldosterone causes the kidneys to retain sodium and water Kidney secretes renin into the bloodstream Sodium and water retention leads to increases in fluid volume and sodium levels (Eckman, 2008)

Table of Contents Atrial natriuretic peptide (ANP) & Brain natriuretic peptide (BNP)-counteracts the effects of the RAA system • When blood volume and blood pressure increase the heart’s ANP & BNP shut off the renin-angiotensin-aldosterone system, which stabilizes blood volume and blood pressure. Na+ and water will be lost in the urine BP. BP (Eckman, 2008)

Table of Contents When your patient is dehydrated does his ADH secretion increase? True False Correct!! Incorrect

Table of Contents TRUE!! • Because his body was dehydrated , it would try to retain as much fluid as possible (Like a dam) • To retain fluid, ADH secretion increases ADH Click on arrow

Table of Contents When your patient’s blood pressure drops their kidneys respond by: Secreting renin Producing aldosterone Slowing the release of ADH Secreting ANP Correct!! Incorrect Incorrect Incorrect

Table of Contents Correct! The kidneys secrete renin in response to low blood flow or a low sodium level. The eventual effect of renin secretion is BP. • Aldosterone is produced by the adrenal glands • Pituitary gland secretes ADH • ANP is produced and stored in the atria of the heart

Table of Contents Fluid Overload Scenario Noah Watter a 81 yr. old recent widower was admitted today with dehydration. He has a history of hypertrophic cardiomyopathy and hypertension. You will be his nurse today. Noah’s physician orders the following treatments: • IV Fluids • Daily CBC, electrolytes, BUN and • creatinine levels • Orthostatic blood pressures daily • a 15mm Hg drop in blood pressure when • upright or an increase of 15 beats/min in • pulse rate is seen with dehydration iStock_000007337705XSmal

Table of Contents Noah Watters puts on his call light at the end of your shift…. “I’m having problems breathing.” Your Nursing Assessment • Temperature 98.6, HR 70, BP 180/90, RR 32 • Skin pale, +2 pedal edema • Lung sounds have bilateral rales & patient coughing • Bounding pulses 4+ • Urine output 500ml • Noah asks for you to call his wife

Table of Contents Your assessment of Noah leads you to believe….. Noah is now fluid overloaded Noah is showing s/s of pneumonia Noah has adequate tissue perfusion Noah needs to be transferred to the ICU Correct!! Incorrect Incorrect Incorrect

Table of Contents Correct! Noah is showing signs of fluid overload • BP increased to 180/90 is the result of excess volume- blood contains more water than normal, increasing the pressure on the blood vessels • Shortness of breath, rales and cough- as left side of the heart becomes overloaded fluid backs up into the lungs • Pulse amplitude is increased in fluid volume excess • Change in mental status is often seen in the elderly (Taylor, 2011 )

Table of Contents If your patient has poor heart function the body can’t compensate for the extra volume which can lead to pulmonary edema. Click lungs 3 times! • As left side of the heart becomes fluid overloaded and pump efficiency declines , fluid backs up into the lungs. • Patient is SOB, tachypneic, cough • You may hear rales on auscultation of the lungs Hydrostatic pressure forces fluid out of pulmonary blood vessels When amount of fluid is excessive, fluid is forced into the aveoli resulting in pulmonary edema Interstitial Space (Eckman 2008)

Table of Contents You report your assessment to Noah Watter’s physician who orders the following: • Discontinue IV fluids • Chest X ray stat • CBC, electrolytes, BUN, Creatinine & UA stat Results: • CBC: WBC 8,000/mm³ Hgb 19g/dl , Hct 36%, Platelets 350,000/mm³ • Chemistry: Na 135meq/L, K 3.2meq/L CL 115meq/L, HCO3 15 meq/L BUN 5, Creatinine 0.5mg/dl , Glucose 88 • Give 40mg Lasix IVP now. • Give K-Dur 20 Meq PO BID • Oxygen at 2L Click here to view common lab values

Table of Contents Which lab values are abnormal for Noah Watter? Incorrect BUN 5mg/dl and Creatinine 0.5mg/dl Hct 36% K+ 3.2meq/dl All of the above Incorrect Incorrect Correct!

Table of Contents Correct! all of the laboratory values are abnormal • Hct , serum potassium and BUN levels are low due to hemodilution. • Lower proportion of RBC compared to water in the blood. ***Very important to monitor K+ levels especially when receiving Lasix (potassium depleting diuretic) (Eckman 2008)

Table of Contents Fluid overload how it happens • Usually body compensates and restores fluid balance (hormones) • If patient has poor heart function the body can’t compensate for the extra volume (will see increased BP) • Fluid is forced out of the blood vessels and moves into the interstitial space causing edema of the tissues (Eckman, 2008)

Table of Contents It is important to evaluate your patients hydration status by monitoring edema and weight gain. • Edema results as hydrostatic (fluid pushing) pressure builds in the vessels, forcing fluid into the tissues • Skin looks puffy and feels cool, pits when touched • Patient gains weight (each 17oz.of fluid= 1lb) • If area is palpated with the fingers an indentation may remain after the pressure is released • Daily weights • Visual assessment • Measurement of affected part (Taylor, 2011)

Table of Contents Factors affecting fluid balance: the stress response • Body’s attempt to adapt to stimuli • Hormones and neurotransmitters that are released during the stress response function to: • Alert individual to a threat to homeostasis • Enhance cardiovascular and metabolic activity in order to manage stressor • Focus energy of the body by suppressing the activity of systems not immediately needed (Porth 2009) Stress Click “stress” to view video!

Table of Contents Neuroendocrine responses to stress • Sympathetic nervous system- (fight or flight response) Click face 4 times! • Increased heart rate • Increased blood • pressure • Pupil dilation • Dry mouth • Increased blood • coagulability Adrenal medulla Epinephrine & Norepinephrine SNS • Activates the RAA system • ADH- also known as vasopressin increases water retention by the kidneys and produces vasoconstriction of blood vessels • Corticotropin releasing factor (CRF )increases ACTH which increases cortisol & aldosterone (Porth 2009)

Table of Contents Inflammatory response also affects fluid balance. Click on the ball to see the how the inflammatory response can lead to decreased blood volume and edema Tissue Damage Damaged cells release prostaglandins and leukotrienes Increased capillary permeability Click 8 times! Exudate leaks out of capillaries into tissues Hypovolemia ( decreased blood volume) Edema of tissues (Bowne, 2011) (Porth, 2011)

Table of Contents Genetics can also affect fluid balance and heart function. • Your patient, Noah Watter has a history of Hypertrophic cardiomyopathy (HCM) . This is an autosomal dominant heart disease caused by mutations in the genes encoding proteins of the cardiac muscle. These mutations impact his heart function which can negatively impact his ability to maintain fluid balance. His heart is affected in following ways: • Left ventrical hypertrophy • Disproportionate thickening of the ventricular septum • Abnormal diastolic filling • Cardiac arrhythmias (Porth 2009)

Table of Contents HCM is just one example of how genetics can affect fluid balance. Any genetic mutation which affects the mechanisms by which the body maintains fluid balance can alter this delicate balance.. Nephronophthisis-medullary cystic disease complex The following are genetic conditions affecting the kidneys. Place mouse over condition for definition! Joubert Syndrome Polycystic Kidney Disease (Venes, 2009) (Porth, 2011) Ren -Related Kidney Disease Alport Syndrome Hypoaldosteronism

Table of Contents Click on the “nurse” to see appropriate nursing interventions • Assess for presence or worsening of FVD • Administer oral fluids if indicated • If patient unable to eat and drink, anticipate TPN or tube feedings to be ordered • Monitor patient’s response to fluid intake, • either oral or parenteral • Be alert for signs of fluid overload • Provide appropriate skin care Fluid Volume Deficit (Taylor, 2011)

Table of Contents Click on the “nurse” to see appropriate nursing interventions • Assess for presence or worsening of FVE • Encourage adherence to sodium-restricted or fluid restricted diet if ordered • Avoid OTC drugs or check with physician or pharmacist about sodium content • Encourage rest periods • Monitor patient’s response to diuretics • Teach self-monitoring of weight and intake and output • Attentive skincare • Monitor respiratory status Fluid volume excess (Taylor, 2011)

Table of Contents H20 Balance Puzzle Click on puzzle piece!

Table of Contents Common Laboratory Values Click here to return to dehydration scenario Click here to return to fluid overload scenario (Pagana , 2006)

Table of Contents References Benelam, B. (2010). Recognizing the signs of dehydration. Practice Nursing, 21(5), 230-234. Bowne, P. (2011). Pat Bowne’s patho. Retrieved from http://faculty.alverno.edu/bowneps/ Eckman, M., Lavine, J., & Thompson, G. (eds). (2008). Fluids & electrolyes made incredibly easy. Lippincott. Gould, B. E., & Dyer, R. M. (2011). Pathophysiology for the health professions. Saunders Elsevier. Licastro, F., Candore, G., Lio, D., Porcellini, E., Colonna-Romano, G., Franceschi, C. et al. (2005, May). Innate immunity and inflammation in ageing; a key for understanding age-related diseases. Immunity & Aging, 2(8), 1-14. Moorhead, S., Johnson, M., Mass, M. L., & Elizabeth, S. (eds). (2008). Nursing outcomes classification (NOC). Mosby. Pagana, K., & Pagana, T. (2006). Mosby's manual of diagnostic and laboratory tests (third edition). Mosby. Porth, C. M., & Matfin, G. (2009). Pathophysiology concepts of altered health states. Lippincott. Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing the art and science of nursing care. Lippincott. Venes, D. (eds). (2009) Taberscyclopedic medical dictionary. 21 edition. F.A. Davis. Woodrow, P. (2003). Assessing fluid balance in older people: Fluid replacement. Nursing Older People, 14(10), 29-30.

The Body’s H20 Balancing Act