this lecture is over the concept of fluid and electrolytes exemplar fluid volume excess also known as fluid overload fluid overload is also referred to as overhydration which is an excess of body fluid it is a clinical indication of a problem in which fluid intake or retention is more than the body's fluid needs most problems caused by fluid overload are related to excessive fluid in the vascular space or to dilution of specific electrolytes and blood components the conditions leading to fluid overload are related to excessive intake or inadequate excretion of fluids the most common type of fluid overload is hypervalmia because the problems result from excessive fluid in the extracellular fluid or ECF space common causes of fluid overload include excessive fluid replacement syndrome of inappropriate antidiuretic hormone SIADH psychiatric disorders with polyypipssia heart failure long-term corticosteroid therapy water intoxication and in latephase kidney failure related to decreased renal profusion leading to impaired fluid excretion the body makes adaptive changes in response to mild or moderate fluid overload especially increased urine output and edema formation these changes are shown here in this diagram the body seeks to adapt and prevent complications but when fluid overload is severe or when it occurs in an adult with poor cardiac or kidney function it can lead to heart failure and pulmonary edema dilution of sodium and potassium may also lead to seizures coma or even death patients with fluid volume overload often have pitting edema in dependent areas this varies with patient position shown here is a grading scale for how we can determine how severe the pitting edema is cardiovascular respiratory skin mucous membrane neuromuscular and gastrointestinal changes are also all very common the symptoms of fluid overload are listed here and are organized by body system cardiovascular changes that you will see with fluid overload include an increased pulse rate bounding pulse quality an elevated blood pressure decreased pulse pressure an elevated central venus pressure distended neck and hand veins engorged varicose veins and weight gain respiratory changes may include increased respiratory rate shallow respirations shortness of breath and moist crackles that are present upon oscultation it is important to make sure that you assess the patient with fluid overload at least every 2 hours to recognize pulmonary edema this may occur very quickly and can lead to death if signs of worsening overload are present you will note things such as a bounding pulse increasing neck vein distension lung crackles increasing peripheral edema and a reduction in urine output if these occur you'll want to respond by notifying the primary health care provider immediately skin and mucous membrane changes are also common pitting edema in dependent areas and the skin feeling very cool to touch and being pale in color are common signs you will note it is important to make sure that we understand that the patient with fluid overload and edema is at risk for skin breakdown it's important to make sure we implement interventions such as pressure reducing or pressure relieving overlays on the mattress and will want to assess skin pressure areas daily for signs of redness or open areas especially on the coxix elbows hips and heels help the patient change position every 2 hours or ensure that assisted personnel are performing this action we also want to be aware of the neuromuscular changes that may occur with fluid overload these include altered levels of consciousness headache visual disturbances skeletal muscle weakness and paristhesas gi changes that may occur include increased motility and enlargement of the liver fluid overload is diagnosed based on assessment findings and the results of laboratory tests usually serum electrolyte values are normal in isotonic fluid overload but decreased hemoglobin hematocrit and serum protein levels may result from excessive water in the vascular space this is referred to as hemod dilution the focus of priority nursing interventions is to ensure patient safety restore normal fluid balance provide supportive care until the imbalance is resolved and prevent future fluid overload patient safety is the first priority interventions are implemented to prevent fluid overload from becoming worse leading to pulmonary edema heart failure and complications of electrolyte dilution any patient with fluid overload regardless of age is at risk for these complications especially when the onset is acute older adults or those with cardiac problems kidney problems pulmonary problems or liver problems are at greatest risk older patients with a history of heart failure are at particularly higher risk of developing pulmonary edema due to the buildup of fluid in the lungs which can lead to shortness of breath and impaired oxygenation drug therapy nutrition therapy and monitoring are the basis of intervention drain is a pneumonic that may be helpful in remembering the interventions used to treat hypervalmia or fluid overload drain stands for diuretics restrictions of fluids and salt assessment of daily weights intake and output and monitoring the sodium level drug therapy focuses on removing excess fluid diuretics are used for fluid overload if kidney function is normal drugs may include high ceiling loop diuretics such as fioamide if there is a concern that too much sodium and other electrolytes would be lost using loop diuretics or if the patient has siadh convapin or tolvapin may be prescribed instead i recommend that you make drug cards for fioamide convapin and tolvapin you'll also want to make sure to monitor the patient for their response to drug therapy especially weight loss and increased urine output nutrition therapy for the patient with chronic fluid overload may involve restrictions of both fluid and sodium intake often sodium restriction involves only no added salt to ordinary table foods if the fluid volume overload is just mild for more severe fluid overload the patient may be restricted to 1.5 to 2 g per day of sodium teach the patient and family how to check food labels for sodium content and how to keep a daily record of sodium ingested fluid retention is not always visible rapid weight gain is the best indicator of fluid retention and overload make sure that you weigh the patient at the same time every day before breakfast using the same scale have the patient wear the same type of clothing for each weigh-in and when we use inbed weights make sure that you lift off the tubing and any equipment off of the bed record the number of blankets and pillows on the bed at the initial weigh-in to ensure the ongoing weights always include the same number if the patient is discharged to home before the fluid overload has completely resolved or if they have continuing risk for fluid overload teach the patient and their family how to monitor their weight at home teach them to keep a record of daily weights to show the healthcare provider at checkups patients may choose to use mobile apps to record and trend this information make sure you instruct the patient to call the primary health care provider if they have more than a three pound weight gain in one week or if they have more than a 2 lb weight gain in 24 hours monitoring intake and output and weight provides information on therapy effectiveness so it is important that these measurements are accurate not just an estimate make sure that you're scheduling fluid offerings throughout the 24-hour periods and make sure that you are teaching assistive personnel to check for urine color and character that may re may indicate infection or that their urine is too concentrated or too diluted so by observing for indications of electrolyte imbalance especially changes in their urine and changes on electroc cardiogram or ECG patterns is essential make sure you're assessing sodium and potassium lab values as well as these may be indicative of fluid imbalance this concludes our lecture on the fluid and electrolyte exemplar fluid volume excess or hypervalmia