NR 341 Week 4 Nursing Care: Complex Fluid Balance Alteration

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Chamberlain University

NR-341 Complex Adult Health

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Nursing Care: Complex Fluid Balance Alterations

Fluid balance disorders in nursing care are multifaceted and can arise from severe burns, trauma, sepsis, and heart failure. These conditions may disturb fluid and electrolyte homeostasis, posing unique challenges for patient management. When caring for patients with fluid imbalances, nurses must tailor interventions to support cardiac output, fluid retention, or elimination as appropriate. For instance, when a patient experiences hypovolemia and decreased preload, administering 0.9% normal saline as an intravenous bolus can help increase preload and improve cardiac output, as opposed to other interventions like nifedipine or furosemide, which may lower preload. When managing a patient with acute respiratory distress syndrome (ARDS), mechanical ventilation can contribute to fluid retention. This occurs due to reduced renal perfusion, which leads to renin release, and subsequently, increased aldosterone secretion, resulting in fluid retention.

Elderly patients admitted with dehydration present unique challenges in fluid management. One example involves administering sodium-free fluids like D5W to correct hypovolemia; however, this intervention may risk complications such as cerebral swelling. In cases where dehydration leads to hyponatremia or fluid overload, careful monitoring of electrolyte levels is essential.

Factors Affecting Fluid Balance and Management

Fluid movement between body compartments is driven by osmosis and diffusion, regulated by three main hormones: aldosterone, antidiuretic hormone (ADH), and natriuretic peptides. Aldosterone plays a role in sodium retention and potassium excretion, often triggered by severe hypotension or hypovolemia. ADH, produced by the pituitary gland, signals renal cells to reabsorb water, reducing urine output while diluting blood plasma. This hormone’s regulation can be altered in conditions like diabetes insipidus or the syndrome of inappropriate ADH secretion (SIADH). In critically ill patients, dysnatremia is a common issue, with either hyponatremia or hypernatremia potentially arising due to improper fluid management or kidney impairment. To address these imbalances, interventions may include restricting water and sodium intake in hypervolemic hyponatremia or administering isotonic solutions for hypernatremic states.

Risk factors for fluid imbalances include cardiac dysfunction, renal impairment, gastrointestinal losses, and certain medications like diuretics. Managing these factors is essential, as dysregulation can lead to fluid volume deficits or excess.

Hemodynamic Monitoring and Nursing Responsibilities

Effective hemodynamic monitoring is central to managing fluid balance in critically ill patients, especially when treating hypo- or hypervolemia. Nurses must be adept in using devices that measure pulmonary artery wedge pressure (PAWP), central venous pressure (CVP), and arterial blood pressure. PAWP offers insights into left ventricular function and helps gauge fluid volume status, with high PAWP values indicating fluid overload and low values indicating volume depletion. Similarly, CVP values assist in diagnosing hypo- or hypervolemia. Ensuring correct setup, zeroing, and calibration of monitoring equipment is crucial to obtain accurate readings.

For patients requiring invasive monitoring, nurses play an active role in equipment preparation, patient education, and monitoring for complications such as infection, thrombus formation, or neurovascular impairment. Continuous renal replacement therapy (CRRT) may be necessary for critically ill patients with fluid overload or impaired kidney function, providing a steady form of fluid removal that stabilizes hemodynamic parameters without excessive strain. Unlike intermittent hemodialysis (IHD), CRRT minimizes fluid shifts, thus offering a safer option for patients in unstable conditions.

Table: Overview of Fluid Management Considerations

Condition	Nursing Interventions	Monitoring Parameters
Hypovolemia	– Administer isotonic fluids (e.g., 0.9% NS) to increase preload. – Monitor urine output and adjust fluid rate as needed. – Assess for signs of dehydration and electrolyte imbalances.	– Urine output ≥ 0.5 ml/kg/hour. – CVP, PAWP, and hemodynamic stability.
Hypervolemia	– Restrict fluid intake as indicated. – Use diuretics (e.g., furosemide) for fluid elimination. – Consider CRRT for critically ill patients with fluid overload and unstable hemodynamic status.	– Monitor CVP, PAWP. – Assess for pulmonary congestion, edema.
Dysnatremia (Hyponatremia/Hypernatremia)	– Administer sodium replacements or restrict sodium as needed based on type (hypo/hypernatremia). – Monitor electrolyte levels closely. – Adjust fluid intake to prevent further imbalance.	– Serum sodium levels. – CVP, PAWP, and signs of neurological status.

Continuous Renal Replacement Therapy (CRRT) Nursing Care

Nursing care during Continuous Renal Replacement Therapy (CRRT) encompasses a range of critical assessments and interventions aimed at monitoring and maintaining patient stability. Initially, nurses should prepare for CRRT by conducting a baseline assessment, which includes monitoring hourly output, assessing fluid volume status, and adjusting fluid replacement as needed based on hourly fluid balances. Regular neurologic assessments and monitoring of electrolyte and acid-base balance are essential. Additionally, the nurse should evaluate the patient’s temperature, assess for signs of bleeding and infection, monitor coagulation status, and ensure the circuit remains patent.

For patients undergoing hemodynamic monitoring, the transducer must be accurately referenced and zeroed. This involves identifying the phlebostatic axis, positioning the transducer appropriately, opening the reference stopcock to room air, and confirming a zero reading on the monitor. In cases where pulmonary auscultation reveals worsening crackles and dyspnea, or when hemodynamic parameters indicate abnormalities—such as decreased cardiac output or elevated pressures—critical interventions may be necessary. Prioritizing accurate readings, zeroing the transducer, and anticipating medication adjustments or additional interventions like dobutamine may be warranted to stabilize the patient.

Shock Nursing Care and Prioritization

Shock is defined as a state of inadequate tissue perfusion resulting in impaired cellular function and potential organ failure. Various forms of shock—cardiogenic, hypovolemic, distributive, and obstructive—can develop based on underlying factors that compromise oxygen delivery. Cardiogenic shock arises from the heart’s inability to pump adequately, often due to conditions such as myocardial infarction or cardiomyopathy. Hypovolemic shock is the most common type and is primarily caused by inadequate fluid volume within the intravascular space. Distributive shock, encompassing septic, anaphylactic, and neurogenic forms, involves systemic vasodilation. Obstructive shock, meanwhile, results from a physical impediment to blood flow, like a pulmonary embolism.

To manage these states, nurses prioritize assessments and interventions specific to each shock type. For example, in cardiogenic shock, cardiac output, stroke volume, and oxygen delivery are critical metrics requiring optimization. Hemodynamic monitoring, medication administration, oxygen therapy, and possibly mechanical assist devices (such as intraaortic balloon pumps or ventricular assist devices) are used to support cardiac function and tissue perfusion. Nurses should be adept at interpreting diagnostic markers like cardiac biomarkers, B-type natriuretic peptide (BNP), and other parameters to guide treatment.

Hypovolemic Shock and Medical Management

In hypovolemic shock, intravascular volume reduction leads to decreased venous return, reduced stroke volume, and diminished cardiac output, all of which jeopardize adequate tissue perfusion. Absolute hypovolemia results from direct fluid loss, while relative hypovolemia involves fluid shifts from the intravascular to the extravascular compartments. Initial compensatory mechanisms, such as the release of catecholamines, aldosterone, and antidiuretic hormone, help maintain vital organ perfusion. However, substantial fluid loss beyond 30% overwhelms compensatory efforts, leading to hypotension, impaired renal function, and decreased cerebral perfusion.

Early signs of hypovolemic shock include anxiety, tachycardia, delayed capillary refill, and pallor. In managing hypovolemic shock, prompt volume replacement with warmed crystalloid solutions or blood products is essential. In severe cases, medical management may also include vasopressors to maintain hemodynamic stability. Monitoring intake, output, laboratory studies, and hemodynamic parameters is critical in managing hypovolemic shock and ensuring effective intervention.

Table 1: Nursing Interventions for CRRT and Types of Shock

CRRT Nursing Care	Shock Types	Medical Interventions for Shock
– Baseline assessment	Cardiogenic Shock	– Goal: Optimize cardiac output and oxygenation
– Monitor hourly CRRT output	– Results from cardiac insufficiency	– Oxygen therapy to achieve PaO₂ > 80 mmHg
– Adjust fluid replacement	– Decreased CO, increased PAWP, CVP	– Medications: Nitrates, Diuretics, Beta-blockers
– Neurologic, electrolyte assessments	Hypovolemic Shock	– Fluid replacement: 3:1 crystalloid for blood loss
– Infection and coagulation monitoring	– Caused by intravascular volume loss	– Hemodynamic support with dopamine
– Ensure circuit patency	– Commonly from hemorrhage, burns	– Continuous monitoring of VS and lab values
– Temperature and bleeding checks	Distributive Shock	Device Interventions
	– Results from systemic vasodilation	– Intraaortic Balloon Pump to decrease cardiac workload
Hemodynamic Monitoring	– Includes septic, anaphylactic types	– Extracorporeal Life Support for severe cases
– Locate and zero transducer	Obstructive Shock
– Positioning at phlebostatic axis	– Caused by blood flow obstruction
– Zero monitor for accuracy	– E.g., pulmonary embolism

Blood Loss and Shock Types

When blood loss reaches a critical level of 1500 ml, immediate administration of packed red cells, along with fresh frozen plasma and platelets, is essential to restore clotting factors. Maintaining arterial oxygen saturation is crucial, often achieved through supplemental oxygen or mechanical ventilation. For unstable patients, positioning in the supine position can assist in stabilizing vital functions.

In cases of distributive shock, widespread vasodilation and increased capillary permeability lead to pooling of blood within the vessels, causing tissue hypoperfusion and impaired cellular metabolism. Distributive shock encompasses three primary types: neurogenic, septic, and anaphylactic.

Neurogenic Shock
Neurogenic shock typically occurs within 30 minutes following a spinal cord injury, especially in the cervical or high thoracic region, and can persist for up to six weeks. This type of shock results from a significant loss of sympathetic nervous system vasoconstrictor tone, leading to extensive vasodilation. Key indicators include hypotension (due to vasodilation), bradycardia (from unopposed parasympathetic tone), and hypothermia due to hypothalamic dysfunction affecting temperature regulation.
Septic Shock
Septic shock arises from an overwhelming inflammatory response, commonly triggered by gram-positive or negative bacterial infections, leading to systemic inflammatory response syndrome (SIRS) and subsequent shock. Common symptoms include tachypnea, tachycardia, and hypotension. Respiratory failure is frequent, initially presenting as respiratory alkalosis due to compensatory hyperventilation, eventually progressing to respiratory acidosis. Other signs include variable temperature and skin changes, progressing from warm and flushed to cool and mottled.
Anaphylactic Shock
This life-threatening hypersensitivity reaction occurs in response to an external agent, causing sudden and severe vasodilation, release of vasoactive mediators, and increased capillary permeability. This rapid response leads to relative hypovolemia, diminished cardiac output, and respiratory distress marked by symptoms like laryngeal edema, bronchospasm, tachycardia, dyspnea, and chest pain.

Diagnostic Findings in Distributive Shock

Neurogenic Shock: May include flaccid paralysis below the injury level and loss of reflex activity.
Septic Shock: Often characterized by elevated or reduced white blood cells, decreased platelets, elevated lactate levels, hyperglycemia, increased urine specific gravity, hyponatremia, and positive blood cultures.
Anaphylactic Shock: Sudden onset of respiratory distress, especially in individuals with known allergies.

Management Approaches

Effective management of distributive shock varies by type. For neurogenic shock, treatment includes stabilizing the spine and using vasopressors to maintain blood pressure. Septic shock management focuses on IV fluid resuscitation, vasopressors, antibiotics, and glucose control. For anaphylactic shock, maintaining an open airway is paramount, with medications like epinephrine, IV fluids, and antihistamines used to counteract the reaction.

Obstructive Shock

Obstructive shock results from physical obstruction in blood flow, commonly due to conditions like cardiac tamponade, tension pneumothorax, or pulmonary embolism. Symptoms include decreased cardiac output and increased afterload. Management focuses on relieving the obstruction through interventions like mechanical decompression, anticoagulant therapy, or surgery, depending on the cause.

Nursing Care: Renal Failure and Kidney Injury

Acute kidney injury (AKI) denotes a sudden decline in kidney function, often associated with life-threatening conditions such as shock or heart failure. Prerenal, intrarenal, and postrenal causes vary from decreased blood flow and glomerular perfusion to direct tissue damage from nephrotoxins or physical obstructions. Nursing care aims to monitor and address complications like fluid imbalance, metabolic acidosis, and electrolyte disturbances to stabilize kidney function.

Type of Shock	Key Characteristics	Management Approach
Neurogenic Shock	Hypotension, bradycardia, hypothermia due to loss of sympathetic tone following spinal cord injury	Stabilize spine, vasopressors for BP, atropine for bradycardia
Septic Shock	Tachypnea, tachycardia, hypotension; causes respiratory failure, hyperventilation, skin changes from warm to cool	IV fluid replacement, vasopressors, antibiotics, glucose control, hemodynamic monitoring
Anaphylactic Shock	Respiratory distress (laryngeal edema, bronchospasm), tachycardia, dizziness, chest pain, pruritus, urticaria	Airway management, epinephrine, IV fluids, antihistamines, corticosteroids
Obstructive Shock	Decreased cardiac output, jugular vein distention, caused by physical obstructions like pulmonary embolism	Relieve obstruction (mechanical decompression, anticoagulants, surgical intervention)
Acute Kidney Injury (AKI)	Impaired kidney function with elevated serum creatinine, BUN, hyperkalemia, risk of progression to chronic kidney disease	Manage fluid, electrolyte balance, monitor for signs of complications such as metabolic acidosis and hyperkalemia
Complications of AKI	Includes fluid volume overload, metabolic acidosis, sodium imbalance, and increased risk of infections	Fluid replacement, monitoring for metabolic acidosis, emergency treatment for hyperkalemia, infection prevention

Neurologic Disorders in Acute Kidney Injury (AKI)

As nitrogenous waste products build up in the brain, various neurologic changes can occur. Initial symptoms may include fatigue and difficulty concentrating. As the condition progresses, more severe manifestations such as seizures and coma may develop.

Diagnostic Studies

Urinalysis
- Presence of urine sediment, including cells, casts, or protein, may suggest intrarenal disorders.
- Urine osmolality, sodium, and specific gravity aid in identifying the specific cause of AKI.
- Hematuria, pyuria, and crystals may be observed with intrarenal AKI. Glucose and protein levels should also be monitored.
Imaging Studies
- Kidney Ultrasound: Assesses for obstructions.
- Renal Scan: Evaluates kidney blood flow, tubular function, and the collecting system.
- CT Scan: Detects lesions, masses, obstructions, and vascular anomalies.
- Renal Biopsy: The most definitive method for confirming intrarenal causes.

Medical Management

The primary goals in managing AKI are eliminating the underlying cause, managing symptoms, and preventing complications.

Fluid Restriction: Limits daily intake to 600 mL plus any previous 24-hour fluid loss.
Diuretic Therapy: Utilizes loop or osmotic diuretics to promote fluid excretion.
Potassium Management: To avoid hyperkalemia, which is a potentially life-threatening complication, the following measures are used:
- Insulin (IV): Temporarily shifts potassium into cells, with concurrent IV glucose to prevent hypoglycemia.
- Sodium Bicarbonate: Helps to shift potassium into cells by correcting acidosis.
- Calcium Gluconate (IV): Stabilizes cardiac cell membranes.
- Sodium Polystyrene Sulfonate: Removes potassium via stool.
- Dialysis: The most effective method for removing potassium rapidly.

Dialysis in AKI

Dialysis is essential for removing waste products and correcting fluid and electrolyte imbalances. There are two primary types:

Peritoneal Dialysis: Uses the peritoneal membrane as a semipermeable barrier. Although suitable for AKI, hemodialysis is more common.
Hemodialysis: Uses an artificial membrane in contact with the blood. Indications for hemodialysis include a glomerular filtration rate (GFR) below 15 mL/min and complications like encephalopathy and hyperkalemia.

Vascular Access

Temporary Access for AKI: A double-lumen catheter is placed in the internal jugular or femoral vein.
Permanent Access for Chronic Kidney Disease (CKD): A subcutaneous arteriovenous fistula (AVF) provides rapid blood flow for hemodialysis.

Continuous Renal Replacement Therapy (CRRT)

CRRT is used to manage fluid overload and hemodynamic instability in critically ill patients. Unlike intermittent hemodialysis, CRRT offers continuous, gentle removal of fluids and waste, improving hemodynamic stability and reducing the risk of cerebral edema. CRRT is primarily used when other methods are insufficient, and its duration can extend up to 30-40 days, with the hemofilter changed every 24-48 hours (Granado & Mehta, 2016).

Dialysis Disequilibrium Syndrome (DDS)

DDS may occur during initial dialysis sessions due to rapid fluid shifts, causing cerebral edema and neurologic symptoms such as headache, confusion, and muscle cramps. Treatment involves discontinuing dialysis and providing supportive care, including airway management and osmotic diuretics.

Nutritional Therapy

In AKI, nutritional support aims to maintain caloric intake and minimize protein breakdown. Patients are advised to consume 30-35 kcal/kg of body weight, prioritize calories from carbohydrates and fats, and restrict sodium intake to prevent edema. Enteral nutrition is preferred, with parenteral nutrition used only if gastrointestinal function is impaired.

Nursing Assessment in AKI

Effective nursing assessment and intervention are crucial in managing AKI. Key responsibilities include:

Daily weight monitoring (1 kg = 1000 mL fluid).
Tracking intake, output, and vital signs.
Monitoring for edema, mental status, and level of consciousness.
Observing lung sounds for fluid accumulation.
Evaluating heart sounds for abnormal rhythms or friction rubs.
Assessing for skin integrity and signs of infection.

References

Assembly Health and Senior Services Committee Statement to Assembly, No. 4098 State of New Jersey. Njleg.state.nj.us. (2011). Retrieved from https://www.njleg.state.nj.us/2010/Bills/A4500/4098_S1.PDF.

Durable Powers of Attorney for Health Care. Lawhelp.org. (2016). Retrieved from https://www.lawhelp.org/dc/resource/frequently-asked-questions-about-durable-power.

New Jersey Board of Nursing: Law and Public Safety. Njconsumeraffairs.gov. (2020). Retrieved from https://www.njconsumeraffairs.gov/regulations/Chapter-37-New-Jersey-Board-ofNursing.pdf.